US Medical Term · insurance
Claims Adjudication
Resolución de reclamaciones
In 9 languages
| Language | Term |
|---|---|
| English | Claims Adjudication |
| Spanish (Español) | Resolución de reclamaciones |
| Chinese (中文) | 理賠核定 |
| Korean (한국어) | 청구 심사 |
| Vietnamese (Tiếng Việt) | Phán quyết bồi thường |
| Filipino (Tagalog) | Pag-adjudicate ng mga claim |
| Portuguese (Português) | Adjudicação de sinistros |
| Thai (ภาษาไทย) | การวินิจฉัยการเรียกร้อง |
| Japanese (日本語) | 保険金審査 |
What it means
Claims adjudication is the process an insurance company uses to review, evaluate, and decide whether to pay, partially pay, or deny a submitted medical claim. During adjudication, the insurer checks eligibility, confirms coverage, verifies medical necessity, applies the correct payment rules, and calculates what the plan owes versus what you owe. The result is communicated on an Explanation of Benefits (EOB) or remittance advice. Adjudication can result in payment, a request for more information, a denial, or a reduction of the charged amount. If your claim is denied during adjudication, you have the right to appeal.
How to say it
Sentences a patient might use with a doctor, nurse, pharmacist, or insurer:
How long does claims adjudication usually take for a surgery claim?
¿Cuánto tiempo suele tomar la resolución de una reclamación por cirugía?
My claim is still in adjudication — can you tell me where it stands?
Mi reclamación sigue en proceso de resolución — ¿puede decirme en qué estado está?
Was my claim denied during adjudication, and what reason was given?
¿Fue rechazada mi reclamación durante la resolución y cuál fue el motivo indicado?
Where you'll see it
Related terms
Sources
Last reviewed: September 2026