Problem Statement

A health plan should pay only when it's the responsible payer, and only after any primary payer has met its obligation. Keeping that straight depends on accurate coordination-of-benefits data — who's primary, what's active, and through what dates — but that information constantly drifts as members gain, lose, and change coverage. Reconciling it manually against payer reports and member records is slow and error-prone, and when COB data is wrong the plan pays as primary when it shouldn't, misses recoverable dollars, or denies claims it actually owes. When a claim arrives without an Explanation of Payment from a primary payer, the plan can't tell whether it's actually primary or whether another payer should have paid first. Each claim in the No-EOP queue has to be checked against the member's COB record for other primary coverage on the same service dates, then either paid as primary or denied so it routes back to the correct payer. Doing this review manually at volume is repetitive, and a wrong call either overpays or wrongly denies.

Automation Solution

This automation works the No-EOP Claims queue in Facets by identifying members without an Explanation of Payment, reviewing the COB tab for primary insurance on the same service dates, and either paying the claim as primary or applying a KZ4 denial.