There are four basic steps to the life cycle of an insurance claim – submission, processing, adjudication, and payment/denial.
Submission is the transmission of claims to an insurance carrier
Processing is completed by the payer by collecting information about the patient, provider, and services performed from the insurance claim form.
Adjudication is when the services and information reported on the claim is compared to payer edits and the patients health benefits to ensure all information needed is available, the claim hasn’t been previously paid, payer rules were followed, and the services billed are covered benefits for the patient.
Rationale: One characteristic that can differentiate the pain of angina from a myocardial infarction is pain that is relieved by rest and nitroglycerine. There may be some exceptions (unstable angina), but the distinction is helpful especially when combined with other assessment data.
