What is an adjudication rule, and where is it applied in Resolute?

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Multiple Choice

What is an adjudication rule, and where is it applied in Resolute?

An adjudication rule is a payor-specific rule that governs how payment is calculated, and it is applied during the adjudication of a claim. In Resolute, these rules encode payer contracts, coverage policies, and the specific payment logic the payer requires. During adjudication, the system uses these rules to determine whether a service is covered, what the allowed amount should be, and any patient or payer adjustments. For example, a rule might specify that a certain CPT code is not covered by a particular payer or that services must be bundled together for payment. This concept is distinct from rules related to data entry order, remittance advice generation, or adjusting pricing type, which occur in different parts of the workflow.

An adjudication rule is a payor-specific rule that governs how payment is calculated, and it is applied during the adjudication of a claim. In Resolute, these rules encode payer contracts, coverage policies, and the specific payment logic the payer requires. During adjudication, the system uses these rules to determine whether a service is covered, what the allowed amount should be, and any patient or payer adjustments. For example, a rule might specify that a certain CPT code is not covered by a particular payer or that services must be bundled together for payment. This concept is distinct from rules related to data entry order, remittance advice generation, or adjusting pricing type, which occur in different parts of the workflow.

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