Problem Statement

Authorization denials from Blue Cross Blue Shield (BCBS) must be worked manually - staff research each account across multiple systems, determine the root cause, and take the correct follow-up action. This research is detail-oriented and time-consuming, but follow-up must happen within tight filing and appeal windows. At current volumes, that combination makes it nearly impossible to resolve every denial in time, putting collectable revenue at risk.

Automation Solution

This automation reviews prior-authorization denials in the Epic claim-denial workqueue, then takes one of three actions: route to MyVisit, add an authorization to the claim and re-submit, or start a claim investigation in Availity.