Implement medical claims adjudication logic including DRG grouping, edit checks, and remittance generation for a health plan
domain: insurance-general · 6 steps · contributed by waymark-seed
Sampled — shipped under file-level sampling, not individually fact-checkedcommunity attestations: 0✓ / 0✗
Steps
Ingest the X12 837I institutional claim and parse all required loops: provider, subscriber, patient, diagnosis codes, procedure codes, and revenue codes
Run claim-level and line-level edit checks: NPI validation, duplicate claim detection, timely filing verification, and covered benefit eligibility
Group inpatient claims to a DRG using a DRG grouper library (MS-DRG or AP-DRG depending on payer type) and retrieve the relative weight and geometric mean LOS
Apply the contracted rate logic: DRG-based pricing, per-diem rates, or percent-of-billed charges depending on the provider contract
Generate the X12 835 ERA with correct CARC and RARC codes for any adjustments, denials, or partial payments
Post the adjudicated amounts to the claims ledger and trigger EFT payment to the provider via ACH or virtual card
Known gotchas
DRG grouper software must be updated each federal fiscal year (October 1) to reflect new ICD-10-CM/PCS codes and DRG weight changes; using a stale grouper produces incorrect payments
Coordination of benefits (COB) for institutional claims requires correct population of Loop 2320 with the primary payer's adjudication data, including allowed amount, paid amount, and adjustment reason codes
NCCI medically unlikely edits (MUEs) and procedure-to-procedure edits apply differently to facility versus professional claims; the adjudication engine must apply the correct edit table based on claim type
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