Which term refers to the final decision in resolving an insurance claim?

Which term refers to the final decision in resolving an insurance claim?

• A. Adjudication
• B. Authorization
• C. Denial
• D. Adjustment

Answer: (A)

Adjudication is the formal determination by the payer after reviewing a claim. It encompasses evaluating eligibility, coverage, and benefit rules, and then issuing the final decision on how much, if anything, will be paid. This is the step where the claim is resolved—whether it will be paid, denied, or paid partially with adjustments. Authorization refers to pre-approval required before a service is provided. Denial is a possible outcome of adjudication, but it’s specifically the decision to reject the claim. Adjustment involves changes to the payment amount or correcting errors after the claim has been reviewed.

Adjudication is the formal determination by the payer after reviewing a claim. It encompasses evaluating eligibility, coverage, and benefit rules, and then issuing the final decision on how much, if anything, will be paid. This is the step where the claim is resolved—whether it will be paid, denied, or paid partially with adjustments.

Authorization refers to pre-approval required before a service is provided. Denial is a possible outcome of adjudication, but it’s specifically the decision to reject the claim. Adjustment involves changes to the payment amount or correcting errors after the claim has been reviewed.