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 helps
Ventus checks claim status with each payer through portals, phone and electronic inquiries, and normalizes the result and any denial reasons across 300+ payers. Your team sees where every claim stands without logging into each payer.
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