Percentage of Claims Completed Within 15 Days

Percentage of Claims Completed Within 15 Days

KPI Details

The Percentage of Claims Completed Within 15 Days measures the volume of medical claims adjudicated by the insurance company within 15 days of reception, which is a highly reasonable timeframe within which to complete a medical claim. A high percentage of claims NOT completed within 15 days can speak to various inefficiencies within the claims processing function: poor inbound claims data quality (e.g., missing information, etc.), a large number of claims processed manually and poor claims intake and routing processes can increase claims cycle times and costs. Extended medical claims settlement cycle times create issues for both health insurance payers and healthcare providers (e.g., physicians, hospitals, pharmacies, etc.). For health insurance companies, long cycle times increase costs, reduce Claims Department employee productivity, and can negatively impact relationships with healthcare providers and policyholders.

KPI Definition

The number of medical insurance claims adjudicated within 15 days of receiving the claim from the healthcare provider divided by the total number of claims adjudicated by the payer over the same period of time, as a percentage.

KPI Best Practices

• Define acceptable levels of claims backlogs based on predictable historical closure rates
• Automate claims intake and adjudication tasks where possible to avoid errors, rework
• Set service level agreements to complete claims in a certain amount of time (i.e., 15 days or less)

KPI Calculation Instructions Percentage of Claims Completed Within 15 Days?

Two numbers are used to calculate this KPI: (1) the number of medical insurance claims adjudicated (paid or denied) within 15 calendar days from the receipt of the claim, and (2) the total number of medical claims adjudicated by the health insurance company over the same period of time. A claim is considered "adjudicated" when it has been reviewed (manually or automatically) and paid (in part or in full) or denied by the insurance company. Do not include claims that are currently pending at the time of measurement in this calculation.

KPI Formula :

(Number of Medical Claims Adjudicated within 15 Days / Total Number of Medical Claims Adjudicated) * 100