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. When a provider is terminated, their records have to be closed out across many parts of the admin system, but only after confirming no active claims remain that need handling first. Working each termination by hand across all those record types is detailed and error-prone, and an incomplete termination leaves stale provider data that can misdirect claims.

Automation Solution

This automation processes provider terminations in Facets by running a claims inquiry on each provider, routing those with active claims for manual review and, for the rest, terminating associated addresses and updating records across IPA, Provider Groups, Payment Info, Out of Networks, and Networks, posting notes from the input file and generating a results file.