Claim adjudication is the process a payer uses to review a submitted insurance claim and decide whether to pay it in full, pay it in part, or deny it.
What it means
Once a provider submits a claim, the payer adjudicates it. The payer checks eligibility, confirms the service is covered, applies the contracted rate, and compares the claim against its rules for medical necessity, coding, and documentation. The output is a payment decision: pay, reduce, or deny.
Adjudication takes time. For commercial payers, the wait between submission and payment commonly runs 30 to 90 days, and longer when a claim is pended for review or kicked back for correction. During that window the claim is valid and moving, but the provider has no cash for the work already delivered.
Adjudication is also where denials originate. A claim that clears the payer's intake edits can still be reduced or denied during adjudication for a coverage or coding reason, which sends it into appeal and resets the clock.
Why it matters for your practice
For a practice, adjudication is the part of the cycle you cannot speed up. You can submit a clean claim and still wait 30 to 90 days for the payer to finish reviewing it. That waiting period is the real cash flow problem: the work is done and documented, but the money to cover payroll and rent is locked inside the payer's process.
How this relates to Copay
Copay removes that wait for the provider. By purchasing your eligible claims and paying the next business day, Copay takes on the 30 to 90 day adjudication wait so you do not have to. You submit claims exactly as you do today, and Copay reconciles when the payer pays. A denied eligible claim is Copay's loss, not yours.
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Written by Eitan Glick, CEO, Copay Inc.
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