Overview of the Claims Adjudication Process for DME Payors

The claims adjudication process for durable medical equipment (DME) billing is a thorough and meticulous task for insurance companies and government programs. Their method of approving and denying claims plays a vital role in your business. Their decision ultimately impacts whether you’ll receive compensation for your orders. 

As a DME provider, you know the effort that goes into submitting a claim for payment and its significant impact on your business. So, if you’ve ever wondered how the claim review process works from the other side, you’re about to learn more about it.

How the DME Claims Adjudication Process Works on the Payor’s Side 

After your billing team submits a claim for payment, the payer begins their part. A simple overview of the claims adjudication process is when the payor (insurance company or government program) reviews your claim and then determines if they’ll pay it in full, partially, or deny it. Then they send the response back to you. 

Now let’s take a look at each step involved during the DME payors claims adjudication process.

Step 1: Receives Claim

The first part of the claims adjudication task begins when the payor receives your claim. Most payors prefer providers to submit claims electronically, although some may accept a hard copy.  

The claims adjudication team performs the first three steps and must ensure the claim information is accurate without any discrepancies. 

Step 2: Validates Claim Information

Before the payor considers reviewing your claim, they check to ensure the initial information is correct. For example, they’ll verify the following patient information.

  • Name 
  • Date of birth 
  • Insurance details 

If any of the above information is incorrect, then they’ll deny or reject the claim and won’t review any of the other details. 

Step 3: Reviews the Entire Claim

Once the adjudication team verifies the claim’s initial details, they’ll review the rest of the data elements. During this step, they’ll:

  • Determine if the claim’s details are accurate
    • HCPCS codes 
    • Modifiers 
    • Patient details 
    • Place of service
    • Various dates 
  • Confirm it meets all current DME guidelines 
  • May contact the provider to ensure all necessary documents were obtained
  • Check to see if it meets their specific policy standard

Working with Your Payor’s Claims Adjudication Team 

At the end of the day, your payor is responsible for ensuring all claims meet their requirements before sending you payment. If they deny your claim, your billing team has the opportunity to correct the information and resubmit it for review again. Taking the necessary steps ahead of time to ensure your claims are clean and accurate can save you a considerable amount of time and effort. 

Additional Assistance from Medbill 

If you and your team are looking for ways to increase your billing efficiency, Medbill can help you. We have a team of DME billers on staff who are experts at all things DME. Connect with us to learn more about how we can take your business to the next level with our billing services. 

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