Healthcare Claims Adjudication Services

Healthcare Claims Adjudication Services

With our healthcare claims adjudication services, we extensively review and identify mistakes in claims before submission to speed up the settlement of claims

Are you swamped with claims that require adjudication? Are you lacking the in-house expertise to handle healthcare and medical claims? If so, we have just the solution to end your woes. Our medical claims adjudication services are designed to end fraudulent claims, limit cost overruns, and add more time to the day to focus on other core competencies.

We have an expert team medical claim examiners who are highly proficient in the adjudication framework. With decades of experience in electronic and manual adjudication, we will adjudicate claims at record speeds. Our team will look for duplicates, errors, and other discrepancies that result in a delay or denial of claims.

Medical Claims Adjudication Services We Offer

Flatworld is a leading healthcare BPO that has professionally handled medical claims processing outsourcing tasks. In just 20 years we have emerged as leaders in the segment because our team of medical claim examiners stays updated on the latest fraud practices. Our claims adjudication services include -

Determination of Claims Value
Explanation of Benefits
Investigation of Claims for Duplicates
Adjudication of Insurance Benefits
Data Extraction from Raw Claims
Checking Data Accuracy with Claims Adjudicating Engine
Review of Diagnostic Code and Patient Data
Evaluation of Healthcare Service Provider Details
In-depth Claims Validation for fraud detection
Execution of Adjudicated Claims
Claims Adjudicating Entitlement
Computing Claims Amount
Coding, Bundling, And Review
Benefit-Based Determination Adjudication

Healthcare Claims Adjudication Process We Follow

Healthcare and medical claims adjudication is a strenuous process that requires comprehensive knowledge of the cost containment measures to fight fraud. This task becomes complicated if you do not have a skilled team to adjudicate claims with agility and precision. Outsourcing claims adjudication to Flatworld solves most of your concerns as we have people who are adept at manual and electronic claims adjudication. Our claims adjudication process is as follows -


Receive Claims Data from You


Check for Eligibility


Check to Avoid Duplicate Claims


Benefit Determination Application


Analysis of Hospital Details


Coding, Bundling & Diagnosis Review


Rules-Based Edits


Claims Settlement


Claims Presentment

Our Healthcare Claims Adjudication Solutions Software

Being one of the leading healthcare claims adjudication service providing companies, we believe in providing quality services within a quick time. This is made possible by leveraging the latest and best healthcare claims adjudication tools and technologies. Some of the key tools and technologies we leverage include -

NextGen healthcare Kareo Billing & EHR eClinicalWorks AdvancedMD brightree medisoft Athenahealth MediTouch athenahealth Billing & EHR AdvancedMd Billing Epic Billing AdvantX Billing CareCloud Billing Centricity Lytec Billing Misys Modernizing Medicine Billing & EHR Nex-tech Billing & EHR Proclaim Pulse SequelMed TotalMD Billing

Claim Types We Adjudicate

We are a world-class healthcare BPO service provider, and our professionals adjudicate the following claim types as part of our healthcare claims adjudication solutions -

 Pends / Correspondence
 HCFA 1500 / CMS 1500
 Vision Forms
 Miscellaneous (Complex / Non-standard)
 Enrollment Forms Processing (EFP)

Multi-layer Review - Our Key Differentiators

At FWS, we continuously try to innovate and optimize our processes by developing smaller process subsets that all our clients can identify with and get behind. Multi-layer claims review is but one example of such a sub-process, which ensures not only up to 100% accuracy but also breakneck speed which is beneficial in the field of healthcare. This includes -

  1. Initial Claims Processing Review

    We believe the first step in the claims review process is also the most important since all claims with simple errors and omissions can be returned at this stage itself, thereby reducing processing load down the line. During this phase, we check for the following -

    • Incorrect patient names and other spelling mistakes
    • Incorrect identification numbers / plan numbers/ member IDs
    • Invalid or missing diagnosis code
    • Incorrect service dates
    • Incorrect service codes
    • Patient's gender mismatch
  2. Automatic Claims Review

    During this phase, an in-depth check of the claims is made to get specific details pertaining to the payer's payment policies. This step is important since many incorrect payouts can be stopped at this stage itself. Issues identified during this phase include -

    • Submission of duplicate claims - Claims which have already been submitted for the same date/procedure/by the same person are flagged

    • Unnecessary Service Delivered - Occasionally claims are made for inappropriate and expensive services which could have been easily avoided for cheaper alternatives or quicker procedures

    • Invalid Diagnosis and Procedure Codes - Diagnostic and procedure codes are sometimes listed wrongly in the claims, and when caught, can save you further trouble

    • Invalid Pre-authorization - Occasionally, the diagnosis, surgery, or performed procedure fails to match with the information provided during pre-authorization

    • Deadline Timing Has Passed - If the medical claim is submitted after the deadline has passed as ascertained by your insurance policy, then the claim processing is stopped

    • Patient Eligibility - If the patient is ineligible to apply for the claim either due to claim mismatch, missed payments, etc., then the claim can be rejected in such a scenario

  3. Final Manual Claims Review

    During this stage, our experienced team of medical and healthcare claims examiners starts checking the claims for the further mismatch. For the same, they may ask for copies of medical records and other relevant documentation to check the authenticity of the claim. This step is extremely crucial when claims are made for unlisted procedures and when the medical necessity for the same needs to be validated.

  4. Payment Determination

    There are mainly three types of payment determinations we use at Flatworld Solutions, they include -

    • Paid - The insurance payer determines the claim can be reimbursed when the healthcare claim is considered paid

    • Denied - The payer determines that the claim cannot be reimbursed when the healthcare claim is considered as denied

    • Reduced - The procedure code can be down-coded when the billed service level is considered too high based on the diagnosis

  5. Payment

    In the final stage, we submit the payment to the office supplied by the payer and is called the explanation of the payment. This includes information such as explanation reasons for the reduction in payment, denial, adjustment, etc. It also includes information such as allowed amount, paid amount, approved amount, covered amount, patient responsibility amount, adjudication date, etc.

    Our exhaustive 5-step verification process ensures all your data is verified so that improper claims are processed properly. We cover a variety of healthcare claim types for our US-based and global clients, including -

    • HCFA claims 1500 / CMS1500
    • UB92 (Single / Multi / Attachment / COB)
    • UB04
    • Dental Claims
    • RX claims
    • Medicaid
    • Foreign claims
    • Superbill
    • Medicare RP
    • Miscellaneous (complex / non-standard)
    • Pends / Correspondence
    • Enrollment Forms Processing (EFP)
    • Vision Claims

Why Are We The Preferred Healthcare Claims Adjudication Services Provider?

Some of the many reasons why partnering with us can help you realize maximum efficiency in the long term includes -

  • Highly Compliant With ISO and Other Frameworks

    We know and understand the intricacies of International insurance regulations and work according to your specific needs, in compliance with international healthcare claims standards and regulations. Therefore, we are an ISO 9001:2015 certified claims adjudication services provider.

  • 100% Data Security

    We are an ISO/IEC 27001:2022 certified organization which ensures that all your patient-related data is completely safe with us. You can be totally confident about the security of your data as we follow stringent data security systems and legally binding security policies.

  • HIPAA Compliant Service Provider

    All our medical claims adjudication services are HIPAA-compliant ensuring strict adherence to laws and regulations.

  • Affordable Services

    We provide our clients with highly affordable pricing options which will suit the clients budget and their business requirement.

  • High-quality Services

    Our claims adjudicators are experts in healthcare claims processing and process your claims with efficient analytical skills, and not as a mindless activity.

  • Proficient Healthcare Claims Adjudicators

    Our adjudicators are specifically trained in US healthcare adjudication systems and processes and provide dedicated healthcare BPO.

  • Quick TAT

    We provide maximum efficiency, quick turnaround time, accurate recording, and up-to-date maintenance of records.

  • Scalable Services

    We provide a scalable solution that enables you to avail additional resources to handle a surge in claims. Our services can be scaled up or down without a fuss.

  • SPOC

    When you choose to outsource claims adjudication services to us, we will assign a dedicated project manager who will keep you always updated about the project status.

  • Latest Technology and Infrastructure

    We use the latest technology in the form of web-based SaaS solutions and remote access solutions to support multiple client platforms from whichever location they prefer.

  • Round-the-clock Support

    We have serviced a variety of different US-based regional and national health plans representing more than 50 satisfied healthcare clients.

Additional Services You Can Benefit From

Medical Transcription Services

We provide HIPAA-compliant medical transcription solutions and services to healthcare providers worldwide.

Medical Billing Services

If you are looking for accurate and reliable medical billing support for your company, we have got you covered. We provide 100% reliable coding services.

Revenue Cycle Management Services

Our RCM services are provided by seasoned medical experts with a firm grasp of the revenue cycle management function.

Medical Coding Services

Our medical coding services are provided by seasoned healthcare professionals with a firm grasp of the concepts in their field.

Pharmacy Business Services

If you are looking for support for your pharmacy business, you are in the right place. We provide comprehensive services for all requirements.

EMR Services

We can remotely manage your EMR and EHR records so that they are spotlessly clean and can be relied upon to make informed decisions.

Telehealth Services

If you are looking to partner with a pioneering provider of telehealth services, you are in the right place. We use digital technologies to make healthcare accessible to all.

Medical Animation Services

We have been designing and creating medical animations for over 20 years. Our seasoned animators have created animations of devices and complex concepts.

Client Success Stories

Demographic and Charge Entry Using Kareo Software

Demographic and Charge Entry Using Kareo Software

A leading Houston-based client was looking for a partner who could help them process more than 17000 claims in a month. Our team provided the services within no time.

Read more
FWS Provided Healthcare Accounts Receivable Services

Healthcare Accounts Receivable Services

A leading client was looking for a partner who could provide them with healthcare account receivable services and improve their cash flow. Our team provided the services within a quick time.

Read more


Vinoth and the team really make my life so much easier! They never skip a beat and I recommend everyone give their services a try. They have become such an integral part of my team. I am glad I found them.

Business Management Consultant, TX, USA
More Testimonials ยป

Outsource Healthcare Claims Adjudication Services to Us

Over the past 20 years, we have been helping global healthcare organizations manage their unique challenges and complex issues such as unplanned volume, omnichannel client communications, claims disbursal and processing, etc. as part of our suite of healthcare BPO services. With our services, you get -

  • Faster claims settlement
  • Enhanced claims accuracy
  • Cost-effective expertise

Contact us now and we will be glad to assist you.

Contact Us


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Flatworld Solutions

116 Village Blvd, Suite 200, Princeton, NJ 08540


Aeon Towers, J.P. Laurel Avenue, Bajada, Davao 8000

KSS Building, Buhangin Road Cor Olive Street, Davao City 8000

Our Customers

  • Movement Mortgage
  • Alcon
  • ARI
  • Maximus
  • Redwood E-Learning Systems

AHIMA Healthcare Convention 2016 Read More