# Adjudicate claims

*/Processes/Adjudicate_claims*

## Digital Scalar

**Band**: digital
**Digital**: 0.85
**Rationale**: With no seeded child occupations available, the scalar is derived directly from the process name and industry lens: 'Adjudicate claims' within 'Direct Health and Medical Insurance Carriers'. Claim adjudication is fundamentally an information-transformation task—reviewing documentation, verifying billing codes, and checking policy coverage—which characterizes high-digital knowledge work. It is assigned a heavily digital scalar accordingly.

## Process Profile

**Outcome**: The claim is finalized as approved, adjusted, or denied, with financial responsibilities calculated and remittance advice generated.
**Trigger**: A medical claim submitted by a healthcare provider or member passes initial data intake and enters the core administration system.
**Key Steps**:
- Verify member eligibility and plan coverage for the dates of service
- Check provider network status, credentials, and contract terms
- Review diagnostic and procedural codes against medical policies and clinical edits
- Apply benefit rules to calculate deductibles, copayments, and coinsurance
- Determine the final allowed amount and insurer payment responsibility
- Generate the Explanation of Benefits (EOB) and electronic remittance advice
**Measured By**:
- [Auto-Adjudication Rate](/Metrics/Auto-Adjudication_Rate)
- [Claims Processing Cycle Time](/Metrics/Claims_Processing_Cycle_Time)
- [Financial Payment Accuracy](/Metrics/Financial_Payment_Accuracy)
- [First-Pass Yield](/Metrics/First-Pass_Yield)

## Boundary Of Firm

**Outsourced To**:
- [Third Party Administrator](/CompanyTypes/Third_Party_Administrator)
- [Claims Processing Outsourcer](/CompanyTypes/Claims_Processing_Outsourcer)
- [Business Process Outsourcing Firm](/CompanyTypes/Business_Process_Outsourcing_Firm)
**Automatability**: augmented
**Routing Summary**:
- Clean, rules-covered claims are auto-adjudicated end to end by a rules engine that checks eligibility, applies the plan's benefit logic, and computes the payable amount.
- Exceptions, suspended edits, and medical-necessity questions are routed in-house to claims examiners and clinical reviewers who hold release authority.
- High-volume routine processing is frequently contracted to a third-party administrator that runs the payer's rule set under delegated authority.
**Delivered By Role**:
- [Claims Examiner](/Processes/Adjudicate_claims/JobTypes/Claims_Examiner)
- [Claims Adjuster](/Processes/Adjudicate_claims/JobTypes/Claims_Adjuster)
- [Medical Claims Reviewer](/Processes/Adjudicate_claims/JobTypes/Medical_Claims_Reviewer)
**Asset Specificity**: specific
**Automated By Action**:
- [Validating Member Eligibility](/Action/Validating_Member_Eligibility)
- [Applying Adjudication Rules](/Action/Applying_Adjudication_Rules)
- [Calculating Benefit Payment](/Action/Calculating_Benefit_Payment)
**Automated By Software**:
- [Claims Adjudication Engine](/Software/Claims_Adjudication_Engine)
- [Auto Adjudication System](/Software/Auto_Adjudication_System)
**Delivered By Department**:
- [Claims Department](/Processes/Adjudicate_claims/Departments/Claims_Department)
- [Claims Operations](/Processes/Adjudicate_claims/Departments/Claims_Operations)

## Neighborhood

### Parent

- [Direct Health and Medical Insurance Carriers](/Industries/Direct_Health_and_Medical_Insurance_Carriers) — parent · Industries

### Siblings

- [Develop and validate new medical technologies](/Processes/Develop_and_validate_new_medical_technologies) — siblings · Processes
- [Research/Resolve payables exceptions](/Processes/Research%2FResolve_payables_exceptions) — siblings · Processes
- [Manage distribution channels](/Processes/Manage_distribution_channels) — siblings · Processes
- [Manage channel partner master data](/Processes/Manage_channel_partner_master_data) — siblings · Processes
- [Identify research collateral, market trends, and technical capabilities](/Processes/Identify_research_collateral,_market_trends,_and_technical_capabilities) — siblings · Processes
- [Design brochures/collateral](/Processes/Design_brochures%2Fcollateral) — siblings · Processes
- [Perform broker channel management](/Processes/Perform_broker_channel_management) — siblings · Processes
- [Profile brokers and agents](/Processes/Profile_brokers_and_agents) — siblings · Processes
- [Contract with brokers and agents](/Processes/Contract_with_brokers_and_agents) — siblings · Processes
- [Manage sales collateral](/Processes/Manage_sales_collateral) — siblings · Processes
- [Manage proposal templates](/Processes/Manage_proposal_templates) — siblings · Processes
- [Analyze purchasing behavior](/Processes/Analyze_purchasing_behavior) — siblings · Processes
- [Analyze customer campaigns](/Processes/Analyze_customer_campaigns) — siblings · Processes
- [Analyze customer market research](/Processes/Analyze_customer_market_research) — siblings · Processes
- [Manage Campaigns](/Processes/Manage_Campaigns) — siblings · Processes
- [Premium payment profile administration](/Processes/Premium_payment_profile_administration) — siblings · Processes
- [Conduct direct sales to groups](/Processes/Conduct_direct_sales_to_groups) — siblings · Processes
- [Produce proposal](/Processes/Produce_proposal) — siblings · Processes
- [Produce renewals](/Processes/Produce_renewals) — siblings · Processes
- [Enroll and onboard membership](/Processes/Enroll_and_onboard_membership) — siblings · Processes
- [Validate members](/Processes/Validate_members) — siblings · Processes
- [Conduct CMS authorization](/Processes/Conduct_CMS_authorization) — siblings · Processes
- [Verify member information](/Processes/Verify_member_information) — siblings · Processes
- [Determine enrollment eligibility](/Processes/Determine_enrollment_eligibility) — siblings · Processes
- [Profile members](/Processes/Profile_members) — siblings · Processes
- [Create and/or modify manage member identifier number](/Processes/Create_and%2For_modify_manage_member_identifier_number) — siblings · Processes
- [Input or update member demographics](/Processes/Input_or_update_member_demographics) — siblings · Processes
- [Input or update confidential communication profile](/Processes/Input_or_update_confidential_communication_profile) — siblings · Processes
- [Input or update ember provider panel/PCP](/Processes/Input_or_update_ember_provider_panel%2FPCP) — siblings · Processes
- [Manage coverage enrollments](/Processes/Manage_coverage_enrollments) — siblings · Processes
- [Collect associate member healthcare information](/Processes/Collect_associate_member_healthcare_information) — siblings · Processes
- [Coordinate benefits](/Processes/Coordinate_benefits) — siblings · Processes
- [Conduct fulfillment administration](/Processes/Conduct_fulfillment_administration) — siblings · Processes
- [Specify appropriate member welcome Letters](/Processes/Specify_appropriate_member_welcome_Letters) — siblings · Processes
- [Specify ID Card Template](/Processes/Specify_ID_Card_Template) — siblings · Processes
- [Specify Benefit Booklet](/Processes/Specify_Benefit_Booklet) — siblings · Processes
- [Install and maintain account/case](/Processes/Install_and_maintain_account%2Fcase) — siblings · Processes
- [Set up account structure and maintenance](/Processes/Set_up_account_structure_and_maintenance) — siblings · Processes
- [Manage group demographics](/Processes/Manage_group_demographics) — siblings · Processes
- [Manage group contacts](/Processes/Manage_group_contacts) — siblings · Processes
- [Verify group information](/Processes/Verify_group_information) — siblings · Processes
- [Verify group participation requirements](/Processes/Verify_group_participation_requirements) — siblings · Processes
- [Manage rate schedules](/Processes/Manage_rate_schedules) — siblings · Processes
- [Perform policy renewal and maintenance](/Processes/Perform_policy_renewal_and_maintenance) — siblings · Processes
- [Generate pre-renewal material (advance notice of change)](/Processes/Generate_pre-renewal_material_(advance_notice_of_change)) — siblings · Processes
- [Conduct early renewal process](/Processes/Conduct_early_renewal_process) — siblings · Processes
- [Conduct annual renewal process](/Processes/Conduct_annual_renewal_process) — siblings · Processes
- [Conduct late renewal process](/Processes/Conduct_late_renewal_process) — siblings · Processes
- [Manage health care delivery](/Processes/Manage_health_care_delivery) — siblings · Processes
- [Generate medical informatics](/Processes/Generate_medical_informatics) — siblings · Processes
- [Perform existing network analysis](/Processes/Perform_existing_network_analysis) — siblings · Processes
- [Perform gap in care analysis](/Processes/Perform_gap_in_care_analysis) — siblings · Processes
- [Perform service and procedure analysis](/Processes/Perform_service_and_procedure_analysis) — siblings · Processes
- [Perform health program management](/Processes/Perform_health_program_management) — siblings · Processes
- [Manage health programs](/Processes/Manage_health_programs) — siblings · Processes
- [Develop health management programs](/Processes/Develop_health_management_programs) — siblings · Processes
- [Manage health program enrollment](/Processes/Manage_health_program_enrollment) — siblings · Processes
- [Perform health program analytics](/Processes/Perform_health_program_analytics) — siblings · Processes
- [Deliver health programs](/Processes/Deliver_health_programs) — siblings · Processes
- [Perform medical policy management](/Processes/Perform_medical_policy_management) — siblings · Processes
- [Develop medical policy rules](/Processes/Develop_medical_policy_rules) — siblings · Processes
- [Monitor medical policy](/Processes/Monitor_medical_policy) — siblings · Processes
- [Review medical policy appeal](/Processes/Review_medical_policy_appeal) — siblings · Processes
- [Perform utilization management](/Processes/Perform_utilization_management) — siblings · Processes
- [Manage prior-authorizations/pre-certify](/Processes/Manage_prior-authorizations%2Fpre-certify) — siblings · Processes
- [Manage provider referral](/Processes/Manage_provider_referral) — siblings · Processes
- [Enforce medical policy](/Processes/Enforce_medical_policy) — siblings · Processes
- [Support healthcare management](/Processes/Support_healthcare_management) — siblings · Processes
- [Develop healthcare management policy, planning, and strategy](/Processes/Develop_healthcare_management_policy,_planning,_and_strategy) — siblings · Processes
- [Develop and maintain contracting and reimbursement policies](/Processes/Develop_and_maintain_contracting_and_reimbursement_policies) — siblings · Processes
- [Develop and maintain medical policies](/Processes/Develop_and_maintain_medical_policies) — siblings · Processes
- [Develop and maintain network strategy and plan](/Processes/Develop_and_maintain_network_strategy_and_plan) — siblings · Processes
- [Develop contracting standards](/Processes/Develop_contracting_standards) — siblings · Processes
- [Manage contract templates](/Processes/Manage_contract_templates) — siblings · Processes
- [Build and maintain standard fee schedules](/Processes/Build_and_maintain_standard_fee_schedules) — siblings · Processes
- [Manage provider rate sheets](/Processes/Manage_provider_rate_sheets) — siblings · Processes
- [Develop and manage the network](/Processes/Develop_and_manage_the_network) — siblings · Processes
- [Identify and recruit providers](/Processes/Identify_and_recruit_providers) — siblings · Processes
- [Credential and re-credential providers](/Processes/Credential_and_re-credential_providers) — siblings · Processes
- [Negotiate and contract with providers](/Processes/Negotiate_and_contract_with_providers) — siblings · Processes
- [Profile providers](/Processes/Profile_providers) — siblings · Processes
- [Manage provider practice/group arrangements](/Processes/Manage_provider_practice%2Fgroup_arrangements) — siblings · Processes
- [Assemble provider market intelligence](/Processes/Assemble_provider_market_intelligence) — siblings · Processes
- [Assemble provider performance indicators](/Processes/Assemble_provider_performance_indicators) — siblings · Processes
- [Manage and monitor providers](/Processes/Manage_and_monitor_providers) — siblings · Processes
- [Manage revenue cycle](/Processes/Manage_revenue_cycle) — siblings · Processes
- [Develop provider communications](/Processes/Develop_provider_communications) — siblings · Processes
- [Educate and train providers](/Processes/Educate_and_train_providers) — siblings · Processes
- [Maintain provider data and directories](/Processes/Maintain_provider_data_and_directories) — siblings · Processes
- [Manage quality and performance of the network management process](/Processes/Manage_quality_and_performance_of_the_network_management_process) — siblings · Processes
- [Manage ancillary services](/Processes/Manage_ancillary_services) — siblings · Processes
- [Manage lab services](/Processes/Manage_lab_services) — siblings · Processes
- [Manage other ancillary services](/Processes/Manage_other_ancillary_services) — siblings · Processes
- [Perform pre-pay provider reimbursement](/Processes/Perform_pre-pay_provider_reimbursement) — siblings · Processes
- [Process encounter information](/Processes/Process_encounter_information) — siblings · Processes
- [Process capitation reimbursement](/Processes/Process_capitation_reimbursement) — siblings · Processes
- [Process and reconcile specialized reimbursements](/Processes/Process_and_reconcile_specialized_reimbursements) — siblings · Processes
- [Perform medical management](/Processes/Perform_medical_management) — siblings · Processes
- [Conduct utilization management](/Processes/Conduct_utilization_management) — siblings · Processes
- [Perform case management and disease management with members](/Processes/Perform_case_management_and_disease_management_with_members) — siblings · Processes
- [Perform referral management for members](/Processes/Perform_referral_management_for_members) — siblings · Processes
- [Promote wellness and patient education](/Processes/Promote_wellness_and_patient_education) — siblings · Processes
- [Manage service provider relationships](/Processes/Manage_service_provider_relationships) — siblings · Processes
- [Manage provider relationships and loyalty](/Processes/Manage_provider_relationships_and_loyalty) — siblings · Processes
- [Manage provider inquiry intake](/Processes/Manage_provider_inquiry_intake) — siblings · Processes
- [Perform provider research and resolve inquiries](/Processes/Perform_provider_research_and_resolve_inquiries) — siblings · Processes
- [Provide orientation, education, and feedback to providers](/Processes/Provide_orientation,_education,_and_feedback_to_providers) — siblings · Processes
- [Conduct provider performance management](/Processes/Conduct_provider_performance_management) — siblings · Processes
- [Coach and train providers](/Processes/Coach_and_train_providers) — siblings · Processes
- [Terminate Provider contracts](/Processes/Terminate_Provider_contracts) — siblings · Processes
- [Manage Provider service quality](/Processes/Manage_Provider_service_quality) — siblings · Processes
- [Communicate with providers](/Processes/Communicate_with_providers) — siblings · Processes
- [Manage provider communication campaigns](/Processes/Manage_provider_communication_campaigns) — siblings · Processes
- [Manage provider requests](/Processes/Manage_provider_requests) — siblings · Processes
- [Conduct pharmacy benefit management](/Processes/Conduct_pharmacy_benefit_management) — siblings · Processes
- [Review member drug utilization](/Processes/Review_member_drug_utilization) — siblings · Processes
- [Manage drug Formulary](/Processes/Manage_drug_Formulary) — siblings · Processes
- [Negotiate formulary rebate](/Processes/Negotiate_formulary_rebate) — siblings · Processes
- [Perform Mail order pharmacy with members](/Processes/Perform_Mail_order_pharmacy_with_members) — siblings · Processes
- [Adjudicate claims and process reimbursement](/Processes/Adjudicate_claims_and_process_reimbursement) — siblings · Processes
- [Develop claim/encounter informatics](/Processes/Develop_claim%2Fencounter_informatics) — siblings · Processes
- [Manage and report on claim processing activity](/Processes/Manage_and_report_on_claim_processing_activity) — siblings · Processes
- [Manage quality assurance and auditing procedures](/Processes/Manage_quality_assurance_and_auditing_procedures) — siblings · Processes
- [Manage critical inquiry process and appeals](/Processes/Manage_critical_inquiry_process_and_appeals) — siblings · Processes
- [Determine coverage/benefits](/Processes/Determine_coverage%2Fbenefits) — siblings · Processes
- [Perform clinical editing](/Processes/Perform_clinical_editing) — siblings · Processes
- [Determine covered service](/Processes/Determine_covered_service) — siblings · Processes
- [Determine eligibility](/Processes/Determine_eligibility) — siblings · Processes
- [Process intake of claims](/Processes/Process_intake_of_claims) — siblings · Processes
- [Enter paper claims into claims system](/Processes/Enter_paper_claims_into_claims_system) — siblings · Processes
- [Enter OCR claims into claims system](/Processes/Enter_OCR_claims_into_claims_system) — siblings · Processes
- [Enter electronic claims into claims system](/Processes/Enter_electronic_claims_into_claims_system) — siblings · Processes
- [Enter interactive claims into claims system](/Processes/Enter_interactive_claims_into_claims_system) — siblings · Processes
- [Create claims imaging and record within claims system](/Processes/Create_claims_imaging_and_record_within_claims_system) — siblings · Processes
- [Assign claim control ID](/Processes/Assign_claim_control_ID) — siblings · Processes
- [Route claims for processing](/Processes/Route_claims_for_processing) — siblings · Processes
- [Conduct pre-edit claims examination](/Processes/Conduct_pre-edit_claims_examination) — siblings · Processes
- [Validate claims](/Processes/Validate_claims) — siblings · Processes
- [Perform claim policy management](/Processes/Perform_claim_policy_management) — siblings · Processes
- [Develop claim policy rules](/Processes/Develop_claim_policy_rules) — siblings · Processes
- [Monitor claim policy](/Processes/Monitor_claim_policy) — siblings · Processes
- [Review claim policy appeal](/Processes/Review_claim_policy_appeal) — siblings · Processes
- [Communicate claim outcomes](/Processes/Communicate_claim_outcomes) — siblings · Processes
- [Generate remittance advise](/Processes/Generate_remittance_advise) — siblings · Processes
- [Generate explanation of benefits](/Processes/Generate_explanation_of_benefits) — siblings · Processes
- [Perform benefits management](/Processes/Perform_benefits_management) — siblings · Processes
- [Provide benefits support](/Processes/Provide_benefits_support) — siblings · Processes
- [Provide benefits administration](/Processes/Provide_benefits_administration) — siblings · Processes
- [Prepare and process claims](/Processes/Prepare_and_process_claims) — siblings · Processes
- [Process reimbursement and notification](/Processes/Process_reimbursement_and_notification) — siblings · Processes
- [Manage other party liabilities](/Processes/Manage_other_party_liabilities) — siblings · Processes
- [Provide explanation of benefits to members](/Processes/Provide_explanation_of_benefits_to_members) — siblings · Processes
- [Manage service protocols](/Processes/Manage_service_protocols) — siblings · Processes
- [Develop service policies and procedures](/Processes/Develop_service_policies_and_procedures) — siblings · Processes
- [Manage service routing and workflow](/Processes/Manage_service_routing_and_workflow) — siblings · Processes
- [Manage documented service level agreements](/Processes/Manage_documented_service_level_agreements) — siblings · Processes
- [Conduct correspondence management](/Processes/Conduct_correspondence_management) — siblings · Processes
- [Track correspondence to case](/Processes/Track_correspondence_to_case) — siblings · Processes
- [Retrieve correspondence image upon request](/Processes/Retrieve_correspondence_image_upon_request) — siblings · Processes
- [Perform member outreach](/Processes/Perform_member_outreach) — siblings · Processes
- [Plan product information](/Processes/Plan_product_information) — siblings · Processes
- [Provide wellness information to members](/Processes/Provide_wellness_information_to_members) — siblings · Processes
- [Manage appeals and grievances](/Processes/Manage_appeals_and_grievances) — siblings · Processes
- [Receive provider claims grievances](/Processes/Receive_provider_claims_grievances) — siblings · Processes
- [Conduct provider claims appeals process](/Processes/Conduct_provider_claims_appeals_process) — siblings · Processes
- [Receive member service grievances](/Processes/Receive_member_service_grievances) — siblings · Processes
- [Perform membership inquiry/eligibility and coverage procedures](/Processes/Perform_membership_inquiry%2Feligibility_and_coverage_procedures) — siblings · Processes
- [Perform billing and payment support processes](/Processes/Perform_billing_and_payment_support_processes) — siblings · Processes
- [Request invoice by member](/Processes/Request_invoice_by_member) — siblings · Processes
- [Update billing and payment profile](/Processes/Update_billing_and_payment_profile) — siblings · Processes
- [Request payment status by member](/Processes/Request_payment_status_by_member) — siblings · Processes
- [Send payment reminder to member](/Processes/Send_payment_reminder_to_member) — siblings · Processes
- [Maintain nurse line help desk](/Processes/Maintain_nurse_line_help_desk) — siblings · Processes
- [Provide wellness support to members](/Processes/Provide_wellness_support_to_members) — siblings · Processes
- [Supply pre-PCP visit support](/Processes/Supply_pre-PCP_visit_support) — siblings · Processes
- [Perform service analytics](/Processes/Perform_service_analytics) — siblings · Processes
- [Manage customer relationships and billing](/Processes/Manage_customer_relationships_and_billing) — siblings · Processes
- [Create account paperwork](/Processes/Create_account_paperwork) — siblings · Processes
- [Manage account relationships](/Processes/Manage_account_relationships) — siblings · Processes
- [Account member setup and maintenance](/Processes/Account_member_setup_and_maintenance) — siblings · Processes
- [Manage account and member setup](/Processes/Manage_account_and_member_setup) — siblings · Processes
- [Maintain member relationships and inquires](/Processes/Maintain_member_relationships_and_inquires) — siblings · Processes
- [Manage member relationships and loyalty](/Processes/Manage_member_relationships_and_loyalty) — siblings · Processes
- [Manage member inquiry intake](/Processes/Manage_member_inquiry_intake) — siblings · Processes
- [Perform research and resolve inquiries](/Processes/Perform_research_and_resolve_inquiries) — siblings · Processes
- [Perform tracking, follow-up, and reporting](/Processes/Perform_tracking,_follow-up,_and_reporting) — siblings · Processes
- [Manage and Process Risk Adjustments](/Processes/Manage_and_Process_Risk_Adjustments) — siblings · Processes
- [Collect data related to Medicare and exchange business](/Processes/Collect_data_related_to_Medicare_and_exchange_business) — siblings · Processes
- [Coordinate experience analysis with medical management](/Processes/Coordinate_experience_analysis_with_medical_management) — siblings · Processes
- [Validate clinical codes and documentation](/Processes/Validate_clinical_codes_and_documentation) — siblings · Processes
- [Update risk scores assumed in pricing](/Processes/Update_risk_scores_assumed_in_pricing) — siblings · Processes
- [Report updated information to CMS](/Processes/Report_updated_information_to_CMS) — siblings · Processes
- [Estimate risk-score related adjustments](/Processes/Estimate_risk-score_related_adjustments) — siblings · Processes
- [Coordinate with finance about payable/receivable](/Processes/Coordinate_with_finance_about_payable%2Freceivable) — siblings · Processes
- [Record and report CMS true-up](/Processes/Record_and_report_CMS_true-up) — siblings · Processes
- [Perform liability and insurance reserve valuations](/Processes/Perform_liability_and_insurance_reserve_valuations) — siblings · Processes
- [Reconcile claim cash flows](/Processes/Reconcile_claim_cash_flows) — siblings · Processes
- [Compile check register entries](/Processes/Compile_check_register_entries) — siblings · Processes
- [Compare check register to cash flow invoices](/Processes/Compare_check_register_to_cash_flow_invoices) — siblings · Processes
- [Reconcile differences](/Processes/Reconcile_differences) — siblings · Processes
- [Process prior period membership eligibility-related adjustments](/Processes/Process_prior_period_membership_eligibility-related_adjustments) — siblings · Processes
- [Process prior period inter-company subrogation-related adjustments](/Processes/Process_prior_period_inter-company_subrogation-related_adjustments) — siblings · Processes
- [Allocate other top side adjustments](/Processes/Allocate_other_top_side_adjustments) — siblings · Processes
- [Apply valuation standards](/Processes/Apply_valuation_standards) — siblings · Processes
- [Compile claim data into required format](/Processes/Compile_claim_data_into_required_format) — siblings · Processes
- [Validate data form and content](/Processes/Validate_data_form_and_content) — siblings · Processes
- [Apply business conditions, operating environment and other assumptions](/Processes/Apply_business_conditions,_operating_environment_and_other_assumptions) — siblings · Processes
- [Perform calculations per actuarial and regulatory standards](/Processes/Perform_calculations_per_actuarial_and_regulatory_standards) — siblings · Processes
- [Reconcile and validate results for changes in business and/or operating environment](/Processes/Reconcile_and_validate_results_for_changes_in_business_and%2For_operating_environment) — siblings · Processes
- [Review results of analysis with management](/Processes/Review_results_of_analysis_with_management) — siblings · Processes
- [Process ledger entries to line of business and legal entity](/Processes/Process_ledger_entries_to_line_of_business_and_legal_entity) — siblings · Processes
- [Issue actuarial opinion by qualified actuary](/Processes/Issue_actuarial_opinion_by_qualified_actuary) — siblings · Processes
- [Manage reserving controls, policies and procedures](/Processes/Manage_reserving_controls,_policies_and_procedures) — siblings · Processes
- [Establish scope and governance of reserve setting function](/Processes/Establish_scope_and_governance_of_reserve_setting_function) — siblings · Processes
- [Establish and publish security and controls guidelines](/Processes/Establish_and_publish_security_and_controls_guidelines) — siblings · Processes
- [Document reserve setting protocols and responsibilities](/Processes/Document_reserve_setting_protocols_and_responsibilities) — siblings · Processes
- [Monitor reserve setting and claim reconciliation procedures](/Processes/Monitor_reserve_setting_and_claim_reconciliation_procedures) — siblings · Processes
- [Audit reserve setting procedures](/Processes/Audit_reserve_setting_procedures) — siblings · Processes
- [Revise and update reserve and liability determination procedures for regulatory or controls related items](/Processes/Revise_and_update_reserve_and_liability_determination_procedures_for_regulatory_or_controls_related_items) — siblings · Processes
- [Develop and confirm internal controls](/Processes/Develop_and_confirm_internal_controls) — siblings · Processes
- [Define system security requirements and permissions](/Processes/Define_system_security_requirements_and_permissions) — siblings · Processes
- [Manage reserves compliance](/Processes/Manage_reserves_compliance) — siblings · Processes
- [Procure update national association insurance commissioners guidelines](/Processes/Procure_update_national_association_insurance_commissioners_guidelines) — siblings · Processes
- [Update procedures manual and tools](/Processes/Update_procedures_manual_and_tools) — siblings · Processes
- [Manage data collection](/Processes/Manage_data_collection) — siblings · Processes
- [Validate associated reported amounts within each risk based capital risk categories](/Processes/Validate_associated_reported_amounts_within_each_risk_based_capital_risk_categories) — siblings · Processes
- [Manage collection of documentation supporting each entry](/Processes/Manage_collection_of_documentation_supporting_each_entry) — siblings · Processes
- [Update reported amounts and documentation](/Processes/Update_reported_amounts_and_documentation) — siblings · Processes
- [Manage application of risk factors](/Processes/Manage_application_of_risk_factors) — siblings · Processes
- [Validate risk exposures against enterprise risk management risk appetites](/Processes/Validate_risk_exposures_against_enterprise_risk_management_risk_appetites) — siblings · Processes
- [Record quantified risk amounts in models](/Processes/Record_quantified_risk_amounts_in_models) — siblings · Processes
- [Manage collection of calculated amounts](/Processes/Manage_collection_of_calculated_amounts) — siblings · Processes
- [Validate regulatory guidance and policies](/Processes/Validate_regulatory_guidance_and_policies) — siblings · Processes
- [Design sensitivity tests and scenarios](/Processes/Design_sensitivity_tests_and_scenarios) — siblings · Processes
- [Review testing parameters with business owners](/Processes/Review_testing_parameters_with_business_owners) — siblings · Processes
- [Perform sensitivity tests](/Processes/Perform_sensitivity_tests) — siblings · Processes
- [Discuss risk and sensitivity results](/Processes/Discuss_risk_and_sensitivity_results) — siblings · Processes
- [Escalate risk awareness against strategies and market objectives](/Processes/Escalate_risk_awareness_against_strategies_and_market_objectives) — siblings · Processes
- [Conduct actuarial services](/Processes/Conduct_actuarial_services) — siblings · Processes
- [Develop trends analysis](/Processes/Develop_trends_analysis) — siblings · Processes
- [Develop cost trend projects](/Processes/Develop_cost_trend_projects) — siblings · Processes
- [Conduct actuarial informatics/reporting](/Processes/Conduct_actuarial_informatics%2Freporting) — siblings · Processes
- [Manage experience rating](/Processes/Manage_experience_rating) — siblings · Processes
- [Perform pre-sale underwriting review](/Processes/Perform_pre-sale_underwriting_review) — siblings · Processes
- [Review claim experience](/Processes/Review_claim_experience) — siblings · Processes
- [Determine premium](/Processes/Determine_premium) — siblings · Processes
- [Perform pool/block rating management](/Processes/Perform_pool%2Fblock_rating_management) — siblings · Processes
- [File with department of insurance](/Processes/File_with_department_of_insurance) — siblings · Processes
- [Develop rating methodology](/Processes/Develop_rating_methodology) — siblings · Processes
- [Publish pool/block rates](/Processes/Publish_pool%2Fblock_rates) — siblings · Processes
- [Manage rating tools](/Processes/Manage_rating_tools) — siblings · Processes
- [Conduct pool/block underwriting](/Processes/Conduct_pool%2Fblock_underwriting) — siblings · Processes
- [Review experience and history](/Processes/Review_experience_and_history) — siblings · Processes
- [Determine pool/block premium](/Processes/Determine_pool%2Fblock_premium) — siblings · Processes
- [Provide underwriting support](/Processes/Provide_underwriting_support) — siblings · Processes
- [Manage regulatory requirements and compliance](/Processes/Manage_regulatory_requirements_and_compliance) — siblings · Processes
- [Manage ORSA regulatory compliance process](/Processes/Manage_ORSA_regulatory_compliance_process) — siblings · Processes
- [Manage fraud, abuse, and payment integrity](/Processes/Manage_fraud,_abuse,_and_payment_integrity) — siblings · Processes
- [Agree on pre-adjudication approach and technology](/Processes/Agree_on_pre-adjudication_approach_and_technology) — siblings · Processes
- [Agree on post-adjudication approach and technology](/Processes/Agree_on_post-adjudication_approach_and_technology) — siblings · Processes
- [Agree on retrospective/post payment approach and recovery](/Processes/Agree_on_retrospective%2Fpost_payment_approach_and_recovery) — siblings · Processes
- [Conduct a vendor selection process](/Processes/Conduct_a_vendor_selection_process) — siblings · Processes
- [Manage government review](/Processes/Manage_government_review) — siblings · Processes

### Related (optimizes)

- [Number of repeat repair/replace claims approved as a percentage of total claims processed](/Metrics/Number_of_repeat_repair%2Freplace_claims_approved_as_a_percentage_of_total_claims_processed) — optimizes · Metrics
- [Claim Cycle Time](/Metrics/Claim_Cycle_Time) — optimizes · Metrics
- [Claim Denial Rate](/Metrics/Claim_Denial_Rate) — optimizes · Metrics
- [Claims Cycle Time](/Metrics/Claims_Cycle_Time) — optimizes · Metrics
- [Payout Accuracy](/Metrics/Payout_Accuracy) — optimizes · Metrics
- [Payout Accuracy Rate](/Metrics/Payout_Accuracy_Rate) — optimizes · Metrics
- [Claim Approval Rate](/Metrics/Claim_Approval_Rate) — optimizes · Metrics
- [Number of invalid or fraudulent claims that are approved per $1 million revenue](/Metrics/Number_of_invalid_or_fraudulent_claims_that_are_approved_per_$1_million_revenue) — optimizes · Metrics

### Related (signature process)

- [Boutique Vertical-Specific BPOs](/CompanyTypes/Boutique_Vertical-Specific_BPOs) — signature process · CompanyTypes
- [Insurance Outsourcing Firm](/CompanyTypes/Insurance_Outsourcing_Firm) — signature process · CompanyTypes
- [Extended Warranty Provider](/CompanyTypes/Extended_Warranty_Provider) — signature process · CompanyTypes
- [Claims Processing Firm](/CompanyTypes/Claims_Processing_Firm) — signature process · CompanyTypes
- [Claims Processing Firms](/CompanyTypes/Claims_Processing_Firms) — signature process · CompanyTypes
- [Claims Processing Provider](/CompanyTypes/Claims_Processing_Provider) — signature process · CompanyTypes
- [Claims Processing Service](/CompanyTypes/Claims_Processing_Service) — signature process · CompanyTypes
- [Claims Processing Service Provider](/CompanyTypes/Claims_Processing_Service_Provider) — signature process · CompanyTypes
- [Pure-Play Administration Company](/CompanyTypes/Pure-Play_Administration_Company) — signature process · CompanyTypes
- [Regional Non-Profit HMOs](/CompanyTypes/Regional_Non-Profit_HMOs) — signature process · CompanyTypes
- [Third Party Administrator](/CompanyTypes/Third_Party_Administrator) — signature process · CompanyTypes
- [Healthcare Business Process Outsourcing Firms](/CompanyTypes/Healthcare_Business_Process_Outsourcing_Firms) — signature process · CompanyTypes
- [Healthcare Claims Processing Company](/CompanyTypes/Healthcare_Claims_Processing_Company) — signature process · CompanyTypes
- [Managed Care Organization](/CompanyTypes/Managed_Care_Organization) — signature process · CompanyTypes
- [Single-State Underwriters](/CompanyTypes/Single-State_Underwriters) — signature process · CompanyTypes
- [Worksite and Group Life Carriers](/CompanyTypes/Worksite_and_Group_Life_Carriers) — signature process · CompanyTypes
- [Global Multi-line Reinsurer](/CompanyTypes/Global_Multi-line_Reinsurer) — signature process · CompanyTypes
- [Claims Processing BPOs](/CompanyTypes/Claims_Processing_BPOs) — signature process · CompanyTypes
- [Mortgage Guaranty Insurers](/CompanyTypes/Mortgage_Guaranty_Insurers) — signature process · CompanyTypes
- [Medicaid Managed Care Organizations (MCOs)](/CompanyTypes/Medicaid_Managed_Care_Organizations_(MCOs)) — signature process · CompanyTypes
- [Regional Provider-Sponsored HMO Centers](/CompanyTypes/Regional_Provider-Sponsored_HMO_Centers) — signature process · CompanyTypes
- [Underwriter Direct Operation](/CompanyTypes/Underwriter_Direct_Operation) — signature process · CompanyTypes
- [Pure-Play Medicare Advantage (MA) Plans](/CompanyTypes/Pure-Play_Medicare_Advantage_(MA)_Plans) — signature process · CompanyTypes
- [Regional Mutual P&C Companies](/CompanyTypes/Regional_Mutual_P&C_Companies) — signature process · CompanyTypes
- [Retail Electronics Warranty Insurers](/CompanyTypes/Retail_Electronics_Warranty_Insurers) — signature process · CompanyTypes
- [Publicly Traded Stock Carriers](/CompanyTypes/Publicly_Traded_Stock_Carriers) — signature process · CompanyTypes
- [Single Parent Captive](/CompanyTypes/Single_Parent_Captive) — signature process · CompanyTypes
- [Enterprise Property & Casualty Carrier](/CompanyTypes/Enterprise_Property_&_Casualty_Carrier) — signature process · CompanyTypes
- [Big Four National Underwriters](/CompanyTypes/Big_Four_National_Underwriters) — signature process · CompanyTypes
- [Self-Funded Health & Welfare TPAs](/CompanyTypes/Self-Funded_Health_&_Welfare_TPAs) — signature process · CompanyTypes
- [Event Cancellation Insurers](/CompanyTypes/Event_Cancellation_Insurers) — signature process · CompanyTypes
- [Lloyd's Reinsurance Syndicate](/CompanyTypes/Lloyd's_Reinsurance_Syndicate) — signature process · CompanyTypes
- [High-Net-Worth Estate Planning Carriers](/CompanyTypes/High-Net-Worth_Estate_Planning_Carriers) — signature process · CompanyTypes
- [Specialty Reinsurer](/CompanyTypes/Specialty_Reinsurer) — signature process · CompanyTypes
- [Voluntary Employees' Beneficiary Associations (VEBAs)](/CompanyTypes/Voluntary_Employees'_Beneficiary_Associations_(VEBAs)) — signature process · CompanyTypes
- [Travel Insurance Carriers](/CompanyTypes/Travel_Insurance_Carriers) — signature process · CompanyTypes
- [Provider-Sponsored Health Plans](/CompanyTypes/Provider-Sponsored_Health_Plans) — signature process · CompanyTypes
- [Mutual Life Insurance Companies](/CompanyTypes/Mutual_Life_Insurance_Companies) — signature process · CompanyTypes
- [Regional Blues (BCBS Affiliates)](/CompanyTypes/Regional_Blues_(BCBS_Affiliates)) — signature process · CompanyTypes
- [National Commercial Multiline Insurers](/CompanyTypes/National_Commercial_Multiline_Insurers) — signature process · CompanyTypes
- [GAP Insurance Underwriters](/CompanyTypes/GAP_Insurance_Underwriters) — signature process · CompanyTypes
- [Staff-Model HMOs](/CompanyTypes/Staff-Model_HMOs) — signature process · CompanyTypes
- [Micro-Captive (831(b))](/CompanyTypes/Micro-Captive_(831(b))) — signature process · CompanyTypes
- [Association Captive](/CompanyTypes/Association_Captive) — signature process · CompanyTypes
- [Medical Professional Liability Carriers](/CompanyTypes/Medical_Professional_Liability_Carriers) — signature process · CompanyTypes
- [Workers' Compensation TPAs](/CompanyTypes/Workers'_Compensation_TPAs) — signature process · CompanyTypes
- [D2C Digital-First Life Carriers](/CompanyTypes/D2C_Digital-First_Life_Carriers) — signature process · CompanyTypes
- [Standard Personal Lines Carriers](/CompanyTypes/Standard_Personal_Lines_Carriers) — signature process · CompanyTypes
- [NEMT Aggregator Network](/CompanyTypes/NEMT_Aggregator_Network) — signature process · CompanyTypes
- [Direct Distribution Underwriters](/CompanyTypes/Direct_Distribution_Underwriters) — signature process · CompanyTypes
- [Excess & Surplus (E&S) Carriers](/CompanyTypes/Excess_&_Surplus_(E&S)_Carriers) — signature process · CompanyTypes
- [Federal Entitlement Administration](/CompanyTypes/Federal_Entitlement_Administration) — signature process · CompanyTypes
- [Specialty & Niche Underwriters](/CompanyTypes/Specialty_&_Niche_Underwriters) — signature process · CompanyTypes
- [Rebate Processing Centers](/CompanyTypes/Rebate_Processing_Centers) — signature process · CompanyTypes
- [Claims Outsourcing Firm](/CompanyTypes/Claims_Outsourcing_Firm) — signature process · CompanyTypes
- [Claims Administration Firm](/CompanyTypes/Claims_Administration_Firm) — signature process · CompanyTypes
- [Home Warranty Providers](/CompanyTypes/Home_Warranty_Providers) — signature process · CompanyTypes
- [Workers' Compensation Board](/CompanyTypes/Workers'_Compensation_Board) — signature process · CompanyTypes
- [Memorial Health Funds](/CompanyTypes/Memorial_Health_Funds) — signature process · CompanyTypes
- [Taft-Hartley Multi-Employer Funds](/CompanyTypes/Taft-Hartley_Multi-Employer_Funds) — signature process · CompanyTypes
- [Employee Benefit & Pension Trusts](/CompanyTypes/Employee_Benefit_&_Pension_Trusts) — signature process · CompanyTypes
- [Taft-Hartley/Multi-Employer Fund Administrators](/CompanyTypes/Taft-Hartley%2FMulti-Employer_Fund_Administrators) — signature process · CompanyTypes
- [Independent Ombudsman Service](/CompanyTypes/Independent_Ombudsman_Service) — signature process · CompanyTypes

### Who runs this

- [Claims Examination](/Departments/Claims_Examination) — runs · Departments

### Industries where this operates

- [Direct Life, Health, and Medical Insurance Carriers](/Industries/Direct_Life,_Health,_and_Medical_Insurance_Carriers) — operates in · Industries

### Rolled up to process group

- [Deliver service to customer](/Processes/Deliver_service_to_customer) — rolled up to process group · Processes

### Problems this exposes

- [adjudicated diagnosis lines feed CMS HCC risk-adjustment submissions, yet coding edits aren't validated for risk-score defensibility](/Problems/adjudicated_diagnosis_lines_feed_CMS_HCC_risk-adjustment_submissions,_yet_coding_edits_aren't_validated_for_risk-score_defensibility) — exposes problem · Problems
- [IBNR reserve and claim-runrate setting depend on adjudication lag the claims queue never surfaces to actuarial](/Problems/IBNR_reserve_and_claim-runrate_setting_depend_on_adjudication_lag_the_claims_queue_never_surfaces_to_actuarial) — exposes problem · Problems
- [state DOI market-conduct exams sample claim-handling timeliness, but the adjudication trail isn't exam-ready evidence](/Problems/state_DOI_market-conduct_exams_sample_claim-handling_timeliness,_but_the_adjudication_trail_isn't_exam-ready_evidence) — exposes problem · Problems
- [adjudication decisions move the 80/85% medical-loss-ratio, but claim-payout outcomes aren't tied to MLR-rebate exposure](/Problems/adjudication_decisions_move_the_80%2F85%25_medical-loss-ratio,_but_claim-payout_outcomes_aren't_tied_to_MLR-rebate_exposure) — exposes problem · Problems
- [adjudication must apply CPT/ICD coding edits and medical-necessity NCD/LCD policy before a coverage decision](/Problems/adjudication_must_apply_CPT%2FICD_coding_edits_and_medical-necessity_NCD%2FLCD_policy_before_a_coverage_decision) — exposes problem · Problems
- [ERISA/ACA appeal and external-review timelines bind denied medical claims to statutory turnaround windows](/Problems/ERISA%2FACA_appeal_and_external-review_timelines_bind_denied_medical_claims_to_statutory_turnaround_windows) — exposes problem · Problems
- [coordination-of-benefits across multiple health payers must resolve before primary adjudication](/Problems/coordination-of-benefits_across_multiple_health_payers_must_resolve_before_primary_adjudication) — exposes problem · Problems
- [fraud-signal triage backlog delays legitimate payouts past regulatory clocks](/Problems/fraud-signal_triage_backlog_delays_legitimate_payouts_past_regulatory_clocks) — exposes problem · Problems
- [appeals re-open closed claims with no version history of the original decision rationale](/Problems/appeals_re-open_closed_claims_with_no_version_history_of_the_original_decision_rationale) — exposes problem · Problems
- [claim-to-policy coverage matching is manual and inconsistent between adjusters](/Problems/claim-to-policy_coverage_matching_is_manual_and_inconsistent_between_adjusters) — exposes problem · Problems
- [duplicate-claim and provider-billing-pattern detection runs after payment, not before](/Problems/duplicate-claim_and_provider-billing-pattern_detection_runs_after_payment,_not_before) — exposes problem · Problems
- [medical/repair-estimate line items not benchmarked against fee schedules or parts catalogs](/Problems/medical%2Frepair-estimate_line_items_not_benchmarked_against_fee_schedules_or_parts_catalogs) — exposes problem · Problems
- [subrogation opportunities missed because liability allocation isn't captured at adjudication](/Problems/subrogation_opportunities_missed_because_liability_allocation_isn't_captured_at_adjudication) — exposes problem · Problems

### Automated by

- [Auto Adjudication System](/Software/Auto_Adjudication_System) — automated by · Software
- [Claims Adjudication Engine](/Software/Claims_Adjudication_Engine) — automated by · Software
- [Calculating Benefit Payment](/Activities/Calculating_Benefit_Payment) — automated by · Activities
- [Applying Adjudication Rules](/Activities/Applying_Adjudication_Rules) — automated by · Activities
- [Validating Member Eligibility](/Activities/Validating_Member_Eligibility) — automated by · Activities

### Outsourced to

- [Business Process Outsourcing Firm](/CompanyTypes/Business_Process_Outsourcing_Firm) — outsourced to · CompanyTypes
- [Claims Processing Outsourcer](/CompanyTypes/Claims_Processing_Outsourcer) — outsourced to · CompanyTypes

### Delivered by

- [Medical Claims Reviewer](/JobTypes/Medical_Claims_Reviewer) — delivered by · JobTypes
- [Claims Adjuster](/JobTypes/Claims_Adjuster) — delivered by · JobTypes
- [Claims Examiner](/JobTypes/Claims_Examiner) — delivered by · JobTypes
- [Claims Operations](/Departments/Claims_Operations) — delivered by · Departments
- [Claims Department](/Departments/Claims_Department) — delivered by · Departments