Problem Statement

On the health-plan side, provider records in the core admin system must be accurate for claims to adjudicate and pay at the correct rate, and reviewing and maintaining them manually across many providers is slow and error-prone. Every newly created or updated provider ID carries a QA User Warning Message that holds its claims in a pend status until the provider passes quality assurance, which keeps claims from paying at an incorrect rate. Once QA passes, the warning has to be removed so the held claims can process, and doing that by hand across each provider ID is repetitive work that leaves claims pended longer than necessary.

Automation Solution

This automation processes claims held in Facets by Quality Assurance User Warning Messages (UWM) once the provider ID passes QA, removing the UWM and releasing the claims for payment at the correct rate from an SQL report.