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Healthcare Claims Adjudication Services

Outsource Healthcare Claims Adjudication Services

Expedite claims execution and contain the risks that impact your profit with accurate and thorough healthcare claims adjudication solutions

Are you unable to achieve fast adjudication by depending on your internal staff? Is your productivity at risk due to claims backlog? Are you losing the competitive edge by processing claims with inaccurate data? End your woes by outsourcing healthcare claims adjudication services to us.

We have dedicated processes to help fight fraud, increase productivity, and boost revenue. Whether it is manual or electronically submitted claims - we will scrutinize the claims record to ensure accuracy in patient names and 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 Solutions We Offer

We have 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. Our healthcare claims adjudication services include -

  • Medical Claims Processing Services

    Medical Claims Processing Services

    We provide comprehensive claims processing services to the healthcare industry, which includes healthcare insurance payers, physician practices, clinics, medical billing companies & hospitals.

  • Medical Claims and Encounter Processing Services

    Medical Claims and Encounter Processing Services

    We manage medical backend tasks, that include claims and encounter processing. Our services have an accuracy rate of 98% and our claims-processing experts can work with short TATs.

  • Remittance Processing Services

    Remittance Processing Services

    We are a leading remittance processing service providing company and we offer reliable remittance processing and accurate evaluations to ensure uninterrupted payments to your practice.

  • Medicare Reimbursement Services

    Medicare Reimbursement Services

    Our services Medicare payments and reimbursements management. We help hospitals and physicians receive payments for the services that they provided to Medicare beneficiaries.

  • Dental Claims Adjudication Services

    Dental Claims Adjudication Services

    Our experts will be your intermediary to adjudicate and can help you settle dental claim disputes and ensure that you receive all the entitlements that are due to you.

Medical Claims Adjudication Services - Types of Claims We Process

We offer comprehensive medical claims adjudication services. We adjudicate medical claims by -

 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

Some of the major types of claims we process include, but are 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 every type of complication that may arise in the claims adjudication process. Our team is experienced at handling such challenges and at understanding process intricacies - to provide efficient services. This is possible by following a systematic and streamlined claims adjudication process. The steps involved in our process are -


01. Initial Processing Review

In the first step, the claims are thoroughly checked for errors and omissions before the claim can be corrected and resubmitted for payment. The claims can be 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

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

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 that is not listed.


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 25 years Experience

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

Why Choose Us As Your Healthcare Claims Adjudication Services Provider?

Being a leading provider of healthcare BPO services to clients worldwide, 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

    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.

  • Data Security

    We are an ISO/IEC 27001:2022 ISMS-certified organization. We sign confidentiality agreements and have data security policies in place to ensure that all your critical data remains completely safe.

  • HIPAA Compliance

    We are extremely strict about adhering to HIPAA regulations. We ensure that patient data is never divulged to any third-party and is completely secure.

  • Best Infrastructure

    We have state-of-the-art infrastructure that includes world-class office spaces, an uninterrupted network, and more. This 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 allows us to deliver results with short turnaround times.

  • Single Point of Contact

    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 scale down the claims adjudication process - as per the client's requirement.

  • 24/7 Availability

    We assign a dedicated project manager, who will be a single point of contact for all your queries and project updates 24/7 via phone, email, or a channel of your choice.

  • 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.

Additional Services You Can Benefit From

Medical Transcription Services

Our comprehensive transcription services support healthcare professionals with the help of experienced transcriptionists who can create accurate and error-free documents for healthcare.

Medical Billing Services

We strictly adhere to HIPAA regulations when we optimize your medical billing and collection processes with the latest billing tools and technologies.

Revenue Cycle Management Services

Our services will streamline your revenue cycle management for less administrative hassles and better revenue. Our experts will efficiently manage your medical RCM requirements.

EMR Services

We boost efficiency and help enhance the quality of care you provide by creating or optimizing your electronic healthcare records system.

Telehealth Services

Streamline the process of telehealth management by efficiently scheduling on-demand visits and video appointments with our telehealth services.

Medical Coding Services

We streamline medical practice management processes related to insurance purposes for healthcare providers by assigning codes to patient charts and organizing patient records.

Customer 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 services.

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 within a short 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 Services to Us

We are a leading healthcare claims adjudication services provider. We have provided a gamut of healthcare BPO services to global clients for over 25 years. All our clients have benefited from the following -

  • We offer high-quality services and operational efficiency
  • We are flexible with using the customer's payment system or our own in-house claims system
  • We constantly update our knowledge base through workshop sessions
  • We make sure to stay equipped against the latest challenges that delay the payment process
  • We provide optimized claims adjudication deliverables

Whatever claims adjudication requirements you have, we can take care of your claims adjudication needs in a professional manner. Get in touch with us today to discuss your project needs.

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