Skip to main content

Payer Coverage Adjudication

Meaning

Payer Coverage Adjudication is the formal, systematic process by which a health insurance company or third-party payer reviews a submitted medical claim or prior authorization request to determine the extent of financial coverage and the final payment responsibility. This complex process involves verifying the patient’s eligibility, assessing the medical necessity of the service against established clinical guidelines, and applying the specific rules of the patient’s health plan benefit structure. The outcome dictates the amount paid by the insurer and the ultimate out-of-pocket cost for the patient.