Claims Adjudication
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The processing of some types of claims can be automated to a great extent. Where there are large volumes of the same type of claim, standards have been developed by the services industry and the insurance industry in order to facilitate this processing. Dental claims, health claims, automobile repair claims are examples of those which have received such attention. For dental claims for example, the dental industry has developed a standard fee schedule which is updated annually and this forms the basis for the amount that would be paid out by an insurer or employee benefits plan. Data standards have been developed to allow the exchange of data betwen dentists and the claims processing firm. When being processed, rules have been developed to validate a current procedure against previous ones, to validate the reasonableness, to check the fees to the point of making a payment, etc. A number of different organizations have evolved to serve these claim adjudication and processing needs. They can bring many skills and tools to bear to provide a solution. See also the latest news in insurance claims.
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