Problem Statement

Claims must be adjudicated correctly the first time, and at volume the manual review needed to catch payment-integrity issues is slow and inconsistent. A readmission to the same provider within a short window may not warrant separate payment, but confirming it means cross-referencing claims across a 60-day span (30 days before and after service) and across Gold, Medicaid, and Commercial lines of business. When this review is skipped or rushed, the plan pays claims it shouldn't, driving improper payments and downstream recovery work, or wrongly denies legitimate ones..

Automation Solution

This automation identifies same-provider readmissions within a 60-day window (30 days before and after service) across Gold, Medicaid, and Commercial claims and determines whether the claim should pay or deny.