What part of the claims process involves comparing the claim to payer edits and the patient's health plan benefits?

The adjudication phase of the claims process is critical because it involves a thorough review of the claim against the payer's established guidelines and the patient’s specific health plan benefits. During this phase, the insurance company evaluates the information included in the claim—such as procedures performed, diagnosis codes, and other relevant details—to ensure that they align with the contractual agreements and policies of the health plan.

This step is essential to determine the validity of the claim, including whether the services rendered are covered under the patient's plan, if they were medically necessary, and what portion of the costs will be paid by the insurer versus what the patient may owe. Adjudication often includes applying any edits set forth by the payer, which may flag discrepancies or necessitate further review for compliance.

In contrast, the submission phase involves sending the claim to the payer, but does not involve this detailed evaluation. The transmission phase relates to the means of sending the claim, such as electronically or via paper, but it does not include any review or comparison aspects. Processing is a broader term that may encompass multiple operational steps, but it is not specifically focused on the detailed evaluation of the claim against payer standards and patient benefits, which is the crux of adjudication.