Claim Adjudication Services We Offer


  • Determination of Claims Value
  • EOBs
  • Investigation of Claims for Duplicates
  • Adjudication of Insurance Benefits
  • Data Retrieval from Unprocessed Claims
  • Data Accuracy Verification Using the Claims Adjudicating Engine
  • Examination of the Patient Data and Diagnostic Code
  • Assessment of Healthcare Service Provider Information
  • Comprehensive Claim Validation to Identify Fraud
  • Fulfilment of Judged Liabilities
  • Claims Adjudicating Entitlement
  • Computing Claims Amount
  • Coding, Bundling, And Review
  • Adjudication Based on Benefit-Based Determination

Types of Claims We Adjudicate

Adjudicate Claim Types

  • HCFA 1500 / CMS 1500
  • UB92/UB04
  • Enrollment Forms Processing (EFP)
  • Vision Forms
  • Pends / Correspondence
  • Dental Claims
  • Remittance Processing Services

What makes us Different ?

  • First Review of Claims Processing

    Since all claims with basic errors and omissions can be returned at this point, we think the initial step in the claims review process is also the most crucial because it reduces the processing load later on. In this stage, we look for the following things:

    • Misspellings and other errors in patient names
    • Inaccurate plan numbers, member IDs, or identity numbers
    • Missing or incorrect diagnostic code
    • Incorrect service dates
    • Incorrect service codes
    • Patient’s gender mismatch
  • Automated Review of Claims

    An extensive review of the claims is conducted at this step in order to obtain particular information about the payer’s payment rules. Since many improper payouts can be halted at this point itself, it is crucial to take this step. Problems found at this stage include:

    • Submitting several claims– Claims that have already been filed for the same date, method, or person are marked.

    • Unnecessary Assistance Provided– Sometimes claims are made for unnecessary and costly services that may have been easily avoided with less expensive options or faster procedures.

    • Erroneous procedure and diagnosis codes– Sometimes diagnostic and procedure codes are listed incorrectly in the claims; if you catch this, it might save you more headaches.

    • Invalid Pre-authorization – Periodically, the information provided during pre-authorization does not match the diagnosis, operation, or procedure that was carried out.

    • Timely Filing Issue – The processing of your claim is halted if the medical claim is filed after the time specified by your insurance policy.

    • Patient Eligibility – The claim may be denied if the patient is not qualified to submit the application because of a claim mismatch, unpaid bills, etc.

  • Complete Manual Review of Claims

    Our skilled group of medical and healthcare claims examiners begins reviewing the claims at this point to look for any additional mismatches. To verify the veracity of the claim, they may also request copies of pertinent medical records and other records. When claims are filed for non-listed operations and the medical necessity of those procedures needs to be verified, this step is vitally important.

  • Payment Determination

    Irevenuebilling primarily employs three kind of payment determinations, which are as follows:

    • Paid – When a healthcare claim is deemed paid, the insurance payer decides whether to repay the claim.

    • Denied – When a healthcare claim is deemed to be refused, the payer determines that the claim is not eligible for reimbursement.

    • Reduced – If the diagnosis indicates that the invoiced service level is excessively high, the procedure code may be downcoded.

  • Payment

    The last step is submitting the payment to the payer’s designated office, which is referred to as the payment explanation. This contains details like the justifications for the payment decrease, rejection, adjustment, etc. Additionally, it contains details like the adjudication date, covered amount, allowed amount, paid amount, approved amount, and patient responsibility amount.

    Our thorough 5-step verification procedure makes sure that all of your data is validated, enabling the correct processing of false claims. For our clients in the US and around the world, we cover a range of healthcare claim types, including: 
    • HCFA claims 1500 / CMS1500
    • UB92 (Single / Multi / Attachment / COB)
    • UB04
    • Superbills

The process We Follow for Claim Adjudication

The adjudication of medical and healthcare claims is a demanding procedure that necessitates in-depth familiarity with cost-cutting strategies to combat fraud. If you lack a competent workforce to quickly and accurately decide claims, this task becomes more difficult. The majority of your worries are resolved when you outsource claims adjudication to Irevenuebilling because we have experts in both manual and computerised claims adjudication. The following describes our claims adjudication procedure:

  • 1. Get Claim Data

    Receive Claims data from yours in any format or type and collect and organize according to the requirements.

  • 2. Advance Eligibility

    Doing Advance eligibility for all the upcoming patients or clients to avoid any shortcomings. We also do prior authorization to increase our efficiency and maximize your reimbursement.

  • 3. Avoid Duplicate Claims

    We make sure to avoid any duplicate claims to increase the efficiency and our our timely response increase reimbursments.

  • 4. Diagnosis, Billing, Bundling and Coding

    We diagnose and do billing, coding and do bundling to increase reimbursement.

  • 5. Payment Posting

    Our medical billing professionals record the amount paid and compare it to the claim that was initially submitted as soon as the payment is received. We make sure that the payments are accurately and swiftly processed.

  • 6. AR Follow and Analyzing Denials

    When claims are rejected or denied, our team takes the required action to fix the problem and guarantee prompt payment. In order to pinpoint areas where the billing procedure needs to be improved, we also examine the causes of the denials.

  • 7. Rule Base edits for extra efficiency

    We have an extra layers of team to ensure 100% efficiency, we do audit, and do any correction if needed to avoid faults and increase profit.

Why We are Supreme in Industry ?

Increase Revenue

Medical businesses may concentrate on tasks that generate income thanks to our specialised services, resulting in higher returns and ongoing profitability.

Affordable Solutions

Medical organisations can acquire top-notch yet inexpensive support by utilising our services. Our global delivery centres are thoughtfully positioned in areas with affordable access to a competent labour force.

Minimum Processing Time

We promise faster service turnaround times because our professionals work from a number of international delivery centres spread across Asia, North America.

Advance Infrastructure

Because our employees work from a number of foreign delivery centres dispersed across Asia and North America, we promise quicker service response times.

Fast Processing

We provide quick scaling alternatives for your operations thanks to our extensive talent pool and global presence. Scale up or down seamlessly as needed, with the least amount of disruption and highest level of effectiveness.

HIPPA Compliance

You can relax knowing that we strictly follow HIPAA regulations and keep up with new needs. Our clients put their trust in us to uphold strict compliance, guaranteeing the protection and privacy of private medical information.