CPB Certified Professional Biller Certification Practice Exam

What is the process of adjudication in medical billing?

1. A preliminary review of claims

2. A final decision-making process by an appeals board

3. A mechanism for patient billing

4. A method of physician-patient negotiations

The correct answer is: A final decision-making process by an appeals board

Adjudication in medical billing refers to the final decision-making process regarding claims submitted to an insurance carrier. During this process, the insurance company assesses the claim to determine whether it meets the necessary criteria for coverage under the patient's plan. This includes checking the patient's eligibility, verifying the services provided against coverage policies, and applying any deductibles, copayments, or coinsurance. The outcome of adjudication can result in the claim being approved for payment, denied, or sent back for additional information. It's a critical step in the claims process as it ultimately dictates what the provider will be reimbursed and what the patient might owe. The other options describe related but distinct processes. For instance, the preliminary review of claims does not encompass the comprehensive evaluation that occurs during adjudication. The mechanism for patient billing and method of physician-patient negotiations are also not part of the adjudication process itself but are instead concerned with financial arrangements and communications between the provider and the patient. Thus, it is the final decision-making aspect of adjudication that is crucial and differentiates it from other processes in medical billing.