What Is Adjudication?

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What Is Adjudication?

Enrolled providers submit claims to ND MMIS for payment for services rendered to Medicaid members. After claim data has been submitted to ND MMIS, several steps are performed to determine whether a claim is paid or denied. This process is known as the adjudication cycle. The edit steps in the adjudication cycle are:

Data Validation - The claim is checked to make sure the right relationships are listed.
Member Eligibility - The claim is checked to make sure the Medicaid member is entitled to receive Medicaid coverage for the dates that services were rendered and that the treatment provided was authorized under North Dakota's Medicaid program.
Provider Eligibility - The ND MMIS provider file verifies that the healthcare practitioner is enrolled and licensed for the claim type, dates of service, and category of service listed on the claim (for example: End Stage Renal Disease (ESRD) - Kidney Disease) treatment administered by a Nephrologist (kidney doctor).
Third Party Liability (TPL) - The claim is checked to determine if another insurance carrier should have paid the claim prior to it being sent to Medicaid. Claims for members with Medicare coverage that haven't been processed yet by those carriers are denied, extracted, and Medicare cross-over transactions sent to the appropriate carrier for payment. <<Is this last sentence accurate???>>
Pricing - ND MMIS checks the type of services rendered to the Medicaid member in order to determine how much to pay the provider. The method of determining an allowable amount to pay for Medicaid services varies among claim types and on some claims it may differ according to the service being billed.
Duplicate Check - ND MMIS compares each claim (prior to payment) against all previously paid claims and claims in process. Any claim that appears to be a duplicate of another causes an exception code to post in the claim record.
Claim Locking - ND MMIS provides the Claim Supervisor or Claims Manager with the capability to unlock claims that are receiving a message that they must be unlocked before a user can access them.

After adjudication, the claims processing function audits and processes claims to final disposition according to the policies and procedures established by DHS.

You use the Adjudication function of Claims to establish criteria that the claims processing function uses to adjudicate claims.

What Is Adjudication?

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