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Claim submission and adjudication, eligibility, prior authorisation, and denials.
3 questions in Healthcare & Life Sciences.
Adjudication validates the member and provider, applies benefit and contract rules, prices the claim and returns a remittance explaining each line. Denials are prevented at the front end by eligibility and prior authorisation checks, and managed at the back end by triaging root causes rather than reworking claims.
Separate the adjudication engine from effective-dated, immutably versioned configuration, resolve config by date of service rather than by today, hold accumulators as a reversible ledger of contributions, adjust decisions by replacement rather than edit, and release config through a replay harness.
Make every hop acknowledge itself and reconcile those acknowledgements actively - envelope receipt, file-level acceptance, then a claim-level acknowledgement from the payer. Until the last of those arrives, the claim is sent but not received, and the difference is a timely-filing denial.