Problem Statement

Claims must be adjudicated correctly the first time, and at volume the manual review needed to catch payment-integrity issues is slow and inconsistent. A second claim from the same provider within seven days of a service date can signal bundling, duplication, or a related-service rule that affects whether the claim should pay, but surfacing those companion claims in Facets by hand is tedious and easy to miss. When the check is missed, the plan risks paying twice for related services and absorbing improper-payment exposure.

Automation Solution

This automation audits Facets claims for the presence of another claim by the same provider within a 7-day window before or after the date of service.