Claims Adjudication & Reconciliation

Outcomes

· More paid claims at first pass
· Accelerated cash posting and fewer write‑offs

Typical deliverables

· Edits & rejects playbook
· Posting workflow redesign
· A/R cleanup sprint
· Weekly metrics report

FAQs

Improve first‑pass rates how?

Pre‑edit checks, eligibility verification, NDC mapping, and real‑time reject workflows.

Best practice for reconciling payments?

Post remittances daily, work short‑pays promptly, and escalate underpayments through appeals.

A/R aging targets?

Aim for most third‑party A/R <30 days; work exceptions weekly.

Data needed for underpayment appeals?

Claim details, contract rate references, MAC lists at fill, remittance codes, payer bulletins.

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