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Healthcare Claims Adjudication Services

Outsource Healthcare Claims Adjudication Services

Our medical claim examiners will perform healthcare claims adjudication services to eliminate fraud, reduce expenses, and enhance your productivity at affordable rates starting at $1280/month

Are you unable to achieve fast adjudication by depending on internal staff? Is your productivity at risk due to claims backlog? Are you losing the competitive edge by processing claims with falsified data? End your woes at once by outsourcing healthcare claims adjudication services to Outsource2india. We have ramped up efforts to fight fraud, increase productivity, and boost revenue with our claims adjudication services.

Whether it is manual or electronically submitted claims we will scrutinize the claims record to ensure accuracy in patient names, diagnostic codes, and process claims that are valid and reimbursable. Our medical claim examiner will closely examine claims after the application of insurance and reject ones that are partially fulfilling, duplicate, or erroneous. Our diligent claims adjudication practices will speed up claims execution and help you contain risks that impact your profit.

Healthcare Claims Adjudication Services We Offer

Outsource2india has experienced teams of medical claim examiners who have decades of experience in manual and electronic claims adjudication. We are proud partners to over 500 hospitals and insurers worldwide. We constantly update our knowledge base via workshop sessions to stay equipped against the latest challenges that delay the payment process. Our healthcare claims adjudication services include -

 Medical Claims Processing
 Medical Claims and Encounter Processing
 Remittance Processing
 Medicare Reimbursement Services
 Dental Claims Adjudication Services
 Determination of benefits
 Verification of provider details
 Detection of fraudulent claims
 Ensuring correctness of raw claims data
 Performing rule-based edit
 Eligibility Checking
 Verification for duplicate claims
 Recommendation of changes to rejected claims

Type of Medical Claims We Adjudicate

Some of the major types of claims we process include, but not limited to -

  • HCFA 1500 / CMS 1500
  • UB92/UB04
  • Dental Claims
  • Pends / Correspondence
  • Enrollment Forms Processing (EFP)
  • Vision Forms
  • Miscellaneous (Complex / Non-standard)

Apart from processing the above-mentioned types of claims, we also have the required skills, expertise, and bandwidth to provide our clients with the following related services -

  • PPO Repricing
  • Forms Processing
  • Insurance Fraud Detection
  • EDI Integration

Healthcare Claims Adjudication Process We Follow

With extensive experience in the healthcare insurance industry, we understand each and every type of complication that may arise in this process. Our team is experienced in handling such complications and understanding process intricacies to provide efficient services within a quick turnaround time. This is possible by following a systematic and streamlined claims adjudication process. The steps involved in our process are listed here -

Initial Processing Review  

01. Initial Processing Review

In the first step, the claims are thoroughly checked for errors and omissions. The claim can be corrected and resubmitted for payment when the claim is rejected for any of the following reasons -

  • Incorrect or wrong patient name
  • Incorrect place of service code
  • Wrong date of service
  • Invalid or missing diagnosis code
  • Wrong plan or subscriber identification number
  • Mismatch of service and patient's gender
Automatic Review  

02. Automatic Review

In this step, claims are checked in detail for items which apply to the payment policies. The issues identified during the automatic review include -

  • Eligibility of the patient on the date of service
  • Absence of authorization and pre-certification
  • Invalid authorization and pre-certification
  • Duplicate claims are submitted
  • Filing deadline has been crossed
  • Invalid procedure or diagnosis code
  • The services are not necessary medically
Manual Review  

03. Manual Review

In this step, medical claim examiners check the claims manually. It is common for nurses and doctors to perform manual checks and compare the medical documentation with the claims. This step is performed for any type of medical procedure and is especially done for a procedure which is not listed.

Payment Determination  

04. Payment Determination

There are basically three types of payment determinations. They are -

  • Paid - If the claim is considered paid, the payer determines if the claim is reimbursable
  • Denied - If the claim is considered denied, the payer determines that the claim is non-reimbursable
  • Reduced - When the billed amount is too high for the diagnosis, the claims examiner can down-code to a lower level as deemed appropriate

05. Payment

The payment submitted by the insurance payer to the medical care provider is referred to an explanation of payment. It includes the following data -

  • Allowed Amount
  • Covered Amount
  • Patient Responsibility Amount
  • Approved Amount
  • Payer Paid Amount
  • Discount Amount
  • Adjudication Date
24 hours
98% Accuracy 40% Cost Reduction 300+ Customers 23 years Experience

Customer-oriented healthcare outsourcing is our forte. Get in touch with us

Why Outsource Healthcare Claims Adjudication Services to Outsource2india?

Being a leading provider of healthcare BPO services to clients worldwide, at Outsource2india, we have the required skills and expertise to handle any type of client requests. Outsourcing claims adjudication services to us can help you take advantage of the following benefits -

  • ISO Certified Claims Adjudication Services Provider

    Outsource claims adjudication services to Outsource2india because we are an ISO 9001:2015 certified company that values your satisfaction. Our service quality is a notch above the rest because we take great care to eliminate errors and missteps in the process.

  • Affordable Services

    All our clients will be billed based on the number of claims processed per day, work volume, etc. This assures quick and efficient services at affordable rates.

  • Data Security

    We are an ISO/IEC 27001:2013 ISMS certified organization. We sign confidentiality agreements and have data security policies in place to ensure that all your critical data remains completely safe with us.

  • HIPAA Compliance

    We sign a HIPAA agreement with every client before we begin the project hence you can be assured that the patient data is divulged to any third-party and be completely secure.

  • Best Infrastructure

    We have the state-of-the-art infrastructure in terms of world-class office spaces, uninterrupted network, etc. which enables us to quickly provide all our clients with world-class services.

  • Leverage Advanced Software

    We make use of some of the latest and updated versions of the best claims adjudication tools and technologies.

  • Quick Turnaround Time

    We have multiple delivery centers around the globe across different time zones, which allow us to deliver the results within a quick turnaround time.

  • Single Point of Contact

    Get a dedicated project manager assigned to handle your priority query. We provide a full-time SPOC who will assist you by conveying your queries to our adjudication team. The responses will be provided without making you wait.

  • Qualified Team of Adjudicators

    Our team comprises of highly skilled, talented, qualified, and experienced adjudicators and insurance experts who are capable of catering to any type of client needs.

  • Easily Scalable Services

    We have the required bandwidth to easily scale up or down the claims adjudication process as per the client's requirement.

  • 24/7 Availability

    We assign a dedicated project manager when you outsource to us who will be a single point of contact for all your queries and project updates 24/7 via phone or email.

Client Success Stories

O2I Helped the Client Streamline their Eligibility Verification Process

Helped the Client Streamline their Eligibility Verification Process

We streamlined eligibility verification, pre-authorization, and A/R follow-up for a reputed medical billing client. The client was elated with our affordable service and expressed their gratification for the value.

Read more
O2I Provided Pharmacy & Medical Insurance Eligibility Services to a Telemedicine Provider

Provided Pharmacy & Medical Insurance Eligibility Services to a Telemedicine Provider

We helped a birth control telemedicine provider with eligibility verification services. Our teams coordinated task to complete the process in a quick TAT.

Read more


Overall I am pleased with the support. The response time and communication were fine. Knowledge of billing and claims was above the expectation. I recommend Outsource2india to those who are contemplating claims adjudication services from an experienced partner.

Medical Device Market Strategy and Reimbursement Company, Tustin, California
More Testimonials »

Outsource Healthcare Claims Adjudication to Us

Outsource2india is a leading company outsourcing claims adjudication services in India and a gamut of other healthcare BPO services to global clients for over 23 years. All our clients have benefited from our high-quality services and operational efficiency. The team at O2I is flexible in adjudicating claims payment by either using the customer's payment system or our own in-house claims system. Whatever claims adjudication requirements you have, we are capable of taking care of your claims adjudication process needs in a professional manner. Get in touch with us today to discuss your project needs.

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