* Is High or Low Best: Higher is Better
Claims Auto-Adjudication Rate measures the number of incoming medical/health insurance claims that are automatically approved or denied (i.e., auto-adjudicated) through a rule-based claims processing system as a percentage of the total number of medical insurance claims received and processed (manually and automatically) over the same period of time. Claims that are auto-adjudicated require no human interaction to process, and consequently cost less, are processed faster, and typically result in less errors than their manually-processed counterparts. Factors impacting health insurance claims auto-adjudication rate include the level of technology implemented by the health insurance payer, claim submission accuracy and completeness, the method of entry into the claims system (electronic vs. manual) and claim complexity (i.e., certain complex medical claims require human involvement).
The total number of claims that are automatically adjudicated (i.e., those approved or denied automatically without need for manual intervention) divided by the total number of claims adjudicated (manual and automatic) over the same period of time, as a percentage.
Two numbers are used to calculate this KPI: (1) the total number of medical claims that were successfully auto-adjudicated over a given time period, and (2) the total number of medical claims adjudicated over the same period of time. A claim that was successfully auto-adjudicated should be counted as any medical claim that was approved or denied automatically by the company’s claims processing system without the need for manual review. A claims that was initially auto-adjudicated but later found to have errors requiring manual resolution should not be included in the numerator for this calculation. For this calculation, the denominator should include ALL medical claims adjudicated (manually and automatically) by the organization during the measurement period.
(Number of Claims Auto-Adjudicated / Total Number of Claims Adjudicated) * 100
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