What does adjudicated a medical claim mean?

Answer 1

Adjudication is the act of making a judicial ruling such as a judgment or decree. In this case a medical claim (probably a civil court case) was decided by a judge.

Update (no offense intended, Bob). In the context of law adjudication is a term for a judicial decision made by a judge. However, in the context of medical claim processing that is not the meaning. In the medical claim context adjudication is the determination of the liability of a payer (insurer) for a submitted claim. There are generally three possible outcomes of adjudication of a claim, whether it is valid and should be paid, it is invalid and should be denied, or more information is need to make a proper determination, in which case it is "pended" for further (usually manual) processing.

The adjudication process itself compares the information on the claim (date of service, who received the service, who rendered the service, the specific services or "procedures" rendered, the diagnosis which justifies the medical need for the rendered services, and other related information such as medical history, etc., and then applies policy rules (often referred to as "edits") to the claim data. In current systems most of this process is automated, and a typical claim may have literally thousands of individual edits applied to it in determining whether it is to be paid or not.

The adjudication process is separate from the pricing process, by which the amount which should be paid is determined. In some systems the adjudication is processed first, and then pricing, in other systems it is done the other way around. In general these are independent processes, each with their own set of policies and business rules to be applied.