Claim Reached Insurance… Now What? | Claim Processing & Adjudication Explained | Episode 07

The healthcare claim has successfully reached the insurance company. But does that mean the hospital gets paid immediately? No. Now the payer has to review the claim and determine what should happen next. Welcome to Episode 07 of RCM Playbook: CLAIM PROCESSING & ADJUDICATION In this episode, we go inside the payer side of the Revenue Cycle Management process and understand how an insurance company reviews a healthcare claim and makes a payment decision. In this video, you will learn: ✅ What is Claim Processing? ✅ What is Claim Adjudication? ✅ Claim Received ≠ Claim Paid ✅ Eligibility / Coverage check on Date of Service ✅ Benefits and service coverage ✅ Prior Authorization review ✅ ICD-10-CM and CPT / HCPCS coding review ✅ Medical Necessity ✅ Provider and Network status ✅ Billed Amount vs Allowed Amount ✅ Patient Responsibility ✅ Deductible, Copay and Coinsurance ✅ Rahul's MRI Claim Case File ✅ What happens when something does not match? ✅ Pending vs Denied ✅ Rejected Claim vs Denied Claim ✅ Automated vs Manual Adjudication ✅ Possible claim outcomes ✅ Paid / Partially Paid / Denied / Pending ✅ EOB & ERA introduction ✅ Important RCM interview questions IMPORTANT CONCEPT: CLAIM SUBMISSION ASKS FOR PAYMENT. CLAIM ADJUDICATION DECIDES THE PAYMENT. A claim reaching the payer does not guarantee payment. Final processing may depend on applicable coverage, benefits, authorization, coding, medical necessity, provider/network requirements, payer contract, patient responsibility and payer rules. 📁 CASE FILE — RAHUL We also follow Rahul's fictional MRI claim and see how the payer may review: Coverage ✅ Benefit ✅ Authorization ✅ Coding ✅ Provider / Network ✅ Pricing ✅ Patient Responsibility ✅ And finally create the payment decision. ⚠️ EDUCATIONAL DISCLAIMER: This video is for educational purposes only. Payer policies, benefit rules, authorization requirements, medical necessity criteria, reimbursement rules and claim-processing workflows may vary by payer, plan, service, provider and situation. All patient names, claim examples and financial amounts used in this video are fictional. Previous Episode: Episode 06 — Claim Submission Next Episode: Episode 08 — EOB & ERA Explained Subscribe to RCM Playbook for simple Hinglish explanations of US Healthcare Revenue Cycle Management, Medical Billing, Denial Management and AR Follow-up. #ClaimAdjudication #ClaimProcessing #MedicalBilling #RCM #RevenueCycleManagement #USHealthcare #HealthcareRCM #ARFollowUp #DenialManagement