What is Adjudication?

Did you know that the word ‘adjudication’ is used in multiple industry’s and carries different meanings for those industries?

If you work in the healthcare payer industry, then claims adjudication and auto-adjudication are terms that you should know very well. Just in case you need a quick reminder, adjudication is the process of reviewing and paying, or denying, claims that have been submitted by a healthcare provider.  

When you go to a medical provider and present your insurance card, the staff will record the insurance information, including that policy number. Once you receive the services from the provider, they will then submit the claim to the insurance company. Thus, beginning the long process that is claims adjudication.

When a TPA, Health Plan, PPO, or any healthcare payer that handles claims, receives a claim from a provider, they will match the insurance number to the patient. This is quick and easy because that policy number is unique to the plan and patient. The challenging part is matching the claims to the correct providers.

Many claims are entered manually leaving room for human error. Common errors that can occur are:

·         Providers names spell wrong / different from what the payer has listed

·         Location address – some providers may work in different locations and types of facilities (i.e. OBGYNs work in both offices and hospitals) or have moved

·         Specialty codes for the services, the providers tax identification numbers, etc.

Once all the claims details are entered into the claims payment system and validated, then the payer must determine the amount needed to be paid to the provider based on their Network and Fee Schedules.  The check is then written and mailed to the provider (hopefully at the appropriate location), completing the adjudication process.

Many healthcare payers have claims payment systems in place that make this process simpler, quicker, with little human involvement, and all around more efficient and cost effective, this is called auto-adjudication. Unfortunately, if information doesn’t match correctly in the system, the claims will go into a provider not found queue and then requires a human to intervene making the process now manual.


BASELoad has been working to help TPAs, PPO, Health Plans, and other healthcare payers to increase their auto-adjudication rate with services that clean, validate, and fulfill medical provider information. Through our custom EDI Provider Matching service, SureHit we have increase payers’ auto-adjudication rate have been proven to reduce payers’ bottom lines. SureHit is currently operating at a 98-99% provider matching accuracy. Wouldn’t it be nice to eliminate the headache of bad provider data and provider not found queues and can bring on new business without having to increase resources and overhead? With BASELoad, you no longer need someone there to manually match providers to claims. Also, with a quicker process and fund disbursement, providers satisfaction rates are sure to increase.


If this is all too familiar and you are needing to increase your auto-adjudication rate, reduce your bottom line, and would like to learn more about BASELoad and our services, give us a call at (704) 424-9889 or email us at info@baseload.com.