Problem Statement

Claims that have already adjudicated often need corrective adjustments, but a reconsideration request first has to reach the right team before anyone can act on it, and routing it correctly depends on the member's coverage. Each request has to be matched to a member, checked for active product coverage on the date of service, and then routed to the downstream queue that matches the product. A wrong route or a missed eligibility problem sends the request to the wrong place and stalls it. Done by hand daily across the queue, this verification and routing is slow and error-prone.

Automation Solution

This automation processes reconsideration requests from the Tower 2MR workqueue by extracting the member number, verifying eligibility and active product coverage in Facets for the date of service, and using a product crosswalk to route each request to the correct downstream workqueue, flagging any that fail member-match or coverage validation in a status report.