What is the process of examining claims and determining benefits by a health plan called?

The process of examining claims and determining benefits by a health plan is referred to as adjudication. This process involves reviewing the submitted claims for accuracy, verifying that the services rendered are covered under the patient’s specific health plan, and assessing the appropriate reimbursement based on the policy terms. Adjudication ensures that claims are assessed fairly and promptly, allowing the health plan to communicate payment determinations effectively to both providers and patients.

The other options do not encapsulate this specific process. Billing compliance pertains to ensuring that billing practices adhere to regulations and guidelines, while review coding compliance focuses on verifying that coded services align with documentation and regulatory standards. Patient check-in pertains to the administrative process of admitting patients for an appointment and does not relate to the evaluation of claims or benefits.