5 Essential Steps to Improve Your Claims Adjudication Process

In the healthcare industry, claims adjudication is critical in determining whether healthcare providers receive accurate and timely reimbursements for their services. This process, however, is often complex and prone to errors, delays, and denials, inhibiting the financial stability of healthcare businesses and compromising patient care.

A recent study by the Kaiser Family Foundation revealed an 18% denial rate for healthcare claims, highlighting the need for efficient and effective claims adjudication processes. Mirra Health Care's Claims Adjudication Solution addresses this challenge by providing a comprehensive offering that streamlines the claims adjudication process, reducing errors and improving reimbursement rates.

This blog post outlines what claims adjudication is, what are the challenges faced by providers and five essential steps healthcare providers can implement to optimize their healthcare claims management process with Mirra's solution. These strategies will enable providers to enhance cash flow, reduce administrative challenges, and focus on providing quality care management services for patients.

Read more: 6 Ways Technology Can Enable Accurate Claims Processing | Mirra HC

What is the Claims Adjudication Process?

Claims adjudication is the organized process health insurance companies use to review and assess healthcare claims to determine how much providers should be paid for the services. This process ensures that claims are accurate, complete, and compliant with the terms of the patient’s health plan.

It typically involves several key steps:

• Initial Review: The insurer checks the claim for basic errors or missing information.
• Automated Checks: Claims are run through rules-based systems to verify eligibility, coverage, coding accuracy, and medical necessity.
• Manual Review (if needed): If anomalies are detected or if the claim is complex, it is reviewed by medical or claims professionals.
• Determination: The insurer approves, denies, or adjusts the claim based on the findings.
• Payment Processing: Once approved, the insurer processes the payment to the provider or reimburses the policyholder.

Challenges Faced by Providers during Claims Adjudication Process 

Health care providers face numerous obstacles in claims adjudication that impact their operational efficiency and financial performance. Processing volume presents a significant challenge as many healthcare organizations handle millions of claims annually, creating substantial operational demands on their systems and staff.

• High Rejection Rates: Initial claim denial rates often exceed 10%, leading to costly follow-ups and resubmissions.
• Extended Revenue Cycles: Providers frequently wait weeks or months for payment, affecting cash flow and financial planning.
• Administrative Burden: Significant time and resources are spent on claims submission, tracking, and appeals, diverting focus from patient care.
• Payer Variation: Inconsistent requirements across multiple payers create complexity, with each insurer having unique guidelines and rules.
• Authorization Complexity: Disconnects between prior authorizations and claims systems lead to delays and denials, despite service approval.
• Financial Uncertainty: Unpredictable adjudication outcomes hinder accurate financial forecasting and planning.
• Resource Allocation Strain: Providers must continuously juggle clinical priorities and administrative demands in resource-constrained environments.

5 Essential Steps to Improve Your Claims Adjudication Process 

To overcome these challenges and improve the efficiency of your claims process, healthcare providers need to adopt a proactive and technology-driven approach. Below are five essential steps that can help streamline workflows, minimize errors, and accelerate reimbursement cycles with the help of Mirra's Claims Adjudication Solution.

Step 1: Harness the Power of Automation 

The Council for Affordable Quality Healthcare (CAQH) estimates that switching to electronic claims submission can save the healthcare industry $1.7 billion (about $5 per person in the US) yearly compared to manual processing. That has significant financial implications for healthcare businesses. Plus, automation can reduce as much as 22 minutes per claim status inquiry, which adds up to a healthier revenue cycle when applied to thousands of claims every month. For payers, it simplifies paperwork, speeds up adjudication, and enhances decision-making using interoperable data. On the provider side, automation ensures data accuracy, prevents duplication, and verifies patient identities.

Mirra’s Claims Adjudication solution leverages automation to convert paper claims into digital records using ClaimsLite®, eliminating manual entry errors and speeding up processing times. Its queue management system automatically routes claims through predefined stages like pending, on hold, payer review, and approved, ensuring consistent workflows and reducing backlogs.

Additionally, automated check management handles voids, reissues, and refunds efficiently, removing manual bottlenecks from the reimbursement process. These automation-driven capabilities help providers achieve faster turnaround times while minimizing errors and operational overhead.

Also, read Benefits of Automating Healthcare Claims Adjudication Solution?

Step 2: Front-End Edits and Coding Checks

Front-end edits and coding checks are pivotal stages of the claims adjudication process. These checks meticulously inspect claims, including all coding and data. They act as the initial filters, detecting inaccuracies, missing information, or discrepancies.

Mirra’s solution strengthens this process with built-in claims editing software, powered by over 40 million edit rules, including CMS NCCI edits. These edits automatically flag issues such as duplicate billing, unbundled codes, or coding conflicts that commonly lead to denials.

The system also performs automatic quality checks like high-dollar reviews and fraud detection. By catching these problems early, providers can reduce denial rates, avoid compliance risks, and speed up claims approval. 

Read more: 7 Benefits of Outsourcing your Medical Claims Management | Mirra HC

Step 3: Efficient Data Management 

Efficient data management ensures the success of the claims adjudication process. Mirra ensures organization, storage, and analysis of the vast data involved in claims. The aim is to ensure this data is accessible, accurate, and secure and can be efficiently used to reduce claims denials.

Mirra’s Claims Adjudication solution offers a comprehensive data management system that centralizes claim-related information, from service and provider details to notes, edits, and documents. Providers can easily access the AR Ledger of their clients, track claim movements, and review activity logs in one place.

The solution also supports global search functionality across claim numbers, patient IDs, and NPIs, enabling teams to retrieve information instantly. With integrated access to member details, prior authorizations, and pricing, the likelihood of data mismatches and submission errors drops significantly.

By organizing and maintaining a clean, secure data environment, Mirra empowers providers to minimize denials and optimize decision-making.

Step 4: Enhance Patient Communication 

Leverage patient participation to streamline claims adjudication. Encourage patients to verify and update their personal information through secure online portals. This reduces errors and ensures accurate data.

Mirra’s solution simplifies this challenge by offering member management features that allow quick access to MOOP ledgers, prior authorizations, and member search tools. These features enable administrative staff to verify patient information, track authorizations, and resolve discrepancies before claim submission.

In addition, Mirra supports the generation of clear, automated communications such as Explanation of Benefits (EOBs) and rejected letters, keeping patients informed about claim status, denials, or necessary next steps. This not only improves transparency but also reduces inbound calls and confusion.

Step 5: Standardize Claims Adjudication 

Standardizing the claims adjudication process ensures consistency across all aspects, streamlining operations and minimizing confusion for healthcare providers. Providers can significantly reduce errors, expedite the claims process, and enhance overall efficiency, improving cash flow and business growth.

Mirra’s Claims Adjudication solution supports standardization through its flexible configuration rules, which allow any benefit structure like HMO, PPO, Dental, Vision to be processed with a high auto-adjudication rate. These rules ensure that claims align with payer-specific guidelines while maintaining internal consistency.

The system also includes structured queue management that categorizes claims into professional, institutional, and dental buckets, with clear status designations like pending, denied, or paid. This enables teams to manage workflows efficiently and reduce variability in processing.

With tools like role-based user management and SSRS/Power BI reports, Mirra ensures transparency, accountability, and actionable insights which are key ingredients for a standardized, scalable claims environment.

Read more: 5 Solutions to Bring Down Your Claims Denial Rate | Mirra HC

The Bottom Line

In a high-stakes environment where every denied claim impact revenue and care delivery, healthcare providers need more than just speed, they need precision, structure, and automation. Mirra Health Care’s Claims Adjudication solution delivers on all fronts.

From digitizing and auto-processing paper claims to running 40 million edit checks and managing member data in one place, Mirra transforms claims adjudication into a streamlined, error-resistant workflow. Built-in tools like global search, structured queue management, EOB generation, and configurable benefit rules empower providers to handle any claim type with confidence.

By adopting Mirra’s claims adjudication platform, providers can minimize denials, maximize operational efficiency, and reclaim valuable time to focus on delivering patient care. You opt for efficiency, accuracy, and an optimized healthcare practice by choosing Mirra's Medicare Advantage in a Box umbrella of solutions. Get in touch with our experts to schedule a demo today.