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. Medicare Secondary Payer rules determine when Medicare pays second to another responsible payer, and getting them wrong is both a compliance and a payment-integrity problem. Each quarter the CMS MSP report has to be reconciled against Facets member data, with HICNs, MSP COB fields, and mismatched dates corrected, claims that were billed incorrectly identified and adjusted, and every change documented. This reconciliation is detailed, high-stakes work that is slow and error-prone manually.

Automation Solution

This automation reconciles the CMS MSP Last Accepted quarterly report against Facets member data, updating HICNs, adjusting MSP COB fields, and reconciling mismatched dates; it identifies incorrectly billed claims, sends provider letters, adjudicates and saves the claim, and documents all changes via member notes in Facets.