Adjudicate claims

Trigger: A medical claim submitted by a healthcare provider or member passes initial data intake and enters the core administration system.

1. Verify member eligibility and plan coverage for the dates of service
2. Check provider network status, credentials, and contract terms
3. Review diagnostic and procedural codes against medical policies and clinical edits
4. Apply benefit rules to calculate deductibles, copayments, and coinsurance
5. Determine the final allowed amount and insurer payment responsibility
6. Generate the Explanation of Benefits (EOB) and electronic remittance advice

Outcome: The claim is finalized as approved, adjusted, or denied, with financial responsibilities calculated and remittance advice generated.