Out-of-Area Logic in Healthcare Claim Adjudication: Framework and Implementation

Authors

Praveen Kumar Vutukuri

Abstract

The healthcare claim adjudication process is a critical component of healthcare systems, ensuring fair reimbursement for services rendered to patients. The "Out-of-Area" (OOA) logic plays a pivotal role in adjudicating claims from providers or patients outside the designated geographic coverage of a health plan. This paper explores the framework, implementation, and challenges of OOA logic in healthcare claim adjudication, providing detailed calculation and automated workflow for real-time processing. We propose a methodology to streamline OOA claim processing while adhering to plan policies and maintaining efficiency.

Keywords

Healthcare Claims, Adjudication, Out-Of-Area Logic, Healthcare Reimbursement, Automation, Geographic Coverage, Payer Policies.

Out-of-Area Logic in Healthcare Claim Adjudication: Framework and Implementation. Praveen Kumar Vutukuri. 2020. IJIRCT, Volume 6, Issue 5. Pages 1-12. https://www.ijirct.org/viewPaper.php?paperId=2412071