Check the medical admissibility of a claim by confirming the diagnosis and treatment details.
· Scrutinize the claims, as per the terms and conditions of the insurance policy
· Interpret the ICD coding, evaluate co-pay details, classify non-medical expenses, room tariff, capping details, differentiation of open billing and package etc.
· Understand the process difference between PA and an RI claim and verify the necessary details accordingly.
· Verify the required documents for processing claims and raise an IR in case of an insufficiency.
· Coordinate with the LCM team in case of higher billing and with the provider team in case of non-availability of tariff.