Quality Rating Systems

Policy Definition: Quality rating systems organize and apply metrics to increase the quality of clinical services, facilitate oversight and help consumers make informed care decisions.

Analytics

Policy Definition: Health Analytics aggregates and analyzes data points that help drive insights into management, costs, patient records, and more. These analytics and data inputs can provide managers with real-time and prospective insights to manage risk and costs, develop care programs and influence operations.

Claims Adjudication

Policy Definition: Claims adjudication is a process by which a payer either accepts or denies responsibility for the payment of a claim. This process is established for payers to determine their payment/financial responsibility after the member’s insurance benefits are applied to a claim.

Coding

Policy Definition: Medical coding is the transformation of health care diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, laboratory and radiologic results, and more. The purpose of coding is for managers to accurately and completely ensure payment and provide insight into areas of improvement. source