How do claims adjudication processes work for MA plans?

• A. Providers file claims directly with CMS, which pays.
• B. Claims are submitted by patients and are always denied.
• C. Claims are submitted by providers, evaluated against plan benefits, and either paid or denied with an explanation and possible appeal options.
• D. Claims are handled solely by the insurance broker.

Answer: (C)

In Medicare Advantage, the claims adjudication process is handled by the MA plan that administers the member’s benefits. Providers submit claims to the MA plan, not to CMS. The plan then reviews the claim against the member’s specific plan benefits, network status, eligibility, and any preauthorization rules. If the service is covered and within the plan’s terms, the plan pays the provider. If it isn’t covered or falls outside the plan’s rules, the claim is denied, and the explanation includes the reason and any steps the member can take to appeal. There is usually an established appeal process for denied claims and for questions about coverage or cost-sharing.

This differs from the other options because CMS does not adjudicate individual MA plan claims, patients don’t typically file claims for MA services themselves, and brokers don’t handle the claims adjudication.