What is the term for the process that examines member eligibility and drug coverage to determine reimbursement?

The process that examines member eligibility and drug coverage to determine reimbursement is known as claims adjudication. This term specifically refers to the systematic review of a claim for payment for health care services, medications, or prescriptions to ensure that it meets the criteria established by the health plan. It involves verifying whether the member is eligible for the service or medication, confirming that it is covered under the member's plan, and determining the appropriate level of reimbursement.

Claims adjudication includes checking that the claim aligns with the formulary guidelines, which are predefined lists of medications covered by the insurance plan. During this process, various factors are assessed, such as the member's copayment or coinsurance responsibilities, prior authorizations if required, and any potential limitations or exclusions related to drug coverage.

The other terms, while related, do not specifically encapsulate the entire process described. For example, eligibility administration mainly focuses on confirming whether a member is eligible for benefits rather than the comprehensive evaluation of claims for reimbursement. Benefit administration encompasses managing and overseeing the benefits offered to members but does not specifically address the adjudication of claims. Formulary management relates to the management of the list of covered drugs rather than the claims payment process itself. Thus, claims adjudication is the term that precisely