What is Claim Adjudication?
Definition
Claim Adjudication is the payer’s process of evaluating a submitted claim against eligibility, coverage, coding edits, and contract terms to determine payment, denial, or pend. It culminates in an ERA/EOB that details allowed amounts, patient responsibility, and reason codes. Example: a $200 billed visit allowed at $140 per contract, with 20% coinsurance ($28) and a bundling denial on an add-on code requiring correction.
Why It Matters
For DSOs and health systems processing tens of thousands of claims monthly, slow or adverse adjudication inflates AR and ties up cash. Cutting 5 AR days on $150M in annual net revenue frees about $2.05M in working capital (150M/365×5), and reducing rework—often $25–$118 per claim—directly improves margin.
How Ventus AI Helps
Ventus AI agents log into payer portals to pull real-time status and adjudication details, normalize reason codes, and compare payments to contracted terms—no payer APIs needed. They auto-initiate reconsiderations or corrected claims, attach required documentation, and route exceptions; at Smilist, Ventus statuses 3,000+ claims weekly using browser-native automation. Agents operate 24/7 to shorten follow-up cycles and prevent 'no claim on file' delays.
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