What is the function of the Claims Review process?

The Claims Review process serves the essential function of evaluating and determining the validity of insurance claims. It involves a thorough examination of the information submitted in the claim to ensure that it meets the necessary criteria for payment. This process not only verifies the authenticity of the claim but also assesses the amount that should be paid to the provider or the insured.

During this review, various factors come into play, including checking that the services billed are covered under the policy, confirming that the care provided was medically necessary, and ensuring that the costs align with the established guidelines or fee schedules. This careful scrutiny helps prevent fraudulent claims and ensures that the insurance company manages their resources effectively while providing necessary benefits to policyholders.

Understanding the claims review process is critical, as it directly impacts both the insurer’s financial health and the insured's access to necessary care. The other options do not align with the primary purpose of the Claims Review process, which focuses specifically on claims evaluation rather than provider assessment, counseling services, or auditing premium payments.