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. Duplicate submissions are common, but not every apparent duplicate is a true one. Confirming it requires comparing each flagged Facets claim against the member's other claims before denying, so legitimate claims aren't wrongly rejected. Done manually off a member list, this is high-volume, repetitive work where a wrong call means either a duplicate payment or an improper denial.

Automation Solution

This automation audits duplicate Facets claims from a SQL-generated member list to confirm whether each claim is a true duplicate and routes them accordingly.