How claim are processed by insurance - paid or denied

Level of Claims Processing


Paper Claim Handling




When the Medicaid fiscal agent receives a paper claim, it is screened for
missing information and necessary attachments. If information or
documentation is missing, the claim will not be entered into the Florida
Medicaid Management Information System (FMMIS). It will be returned to the
provider with a Return to Provider (RTP) letter that will state the reason the
claim is being returned. The provider needs to correct the error, attach any
missing documentation, and return the claim to the fiscal agent for processing.


Claim Entry 
Data entry operators image and key into FMMIS each paper claim that passes
initial screening. Electronic claims are loaded by batch into FMMIS by the
fiscal agent’s data processing staff.

Claim Adjudication 

FMMIS analyzes the claim information and determines the status or disposition
of the claim. This process is known as claim adjudication.

Disposition of Claim


A claim disposition can be:
·  Paid: payment is approved in accordance with program criteria.
·  Suspended: the claim is put on “hold” so it can be analyzed in more detail
by the fiscal agent or AHCA Medicaid.
·  Denied: payment cannot be made because the information supplied
indicates the claim does not meet program criteria, or information necessary
for payment was either erroneous or missing.
Processing Time
Frames
Claims are processed daily. Payments are made on a weekly basis. Under
normal conditions a claim can be processed from receipt to payment within 7 to
30 days.

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