Problem Statement

Claim edits create manual rework before a claim can go out the door, and edits left unresolved either delay submission or, if missed, produce avoidable denials that erode the clean claim rate and push out cash collection. When Medicare flags a claim as a duplicate with a QA18 code, it isn't always a true duplicate, so resolving it means comparing the two claim versions in Epic to see what actually differs and then choosing the right corrective action. That comparison-and-decision is exactly the repetitive analysis that has to follow consistent rules to avoid either re-denying a good claim or paying a true duplicate.

Automation Solution

This automation identifies Medicare claims with duplicate denials (QA18), compares the claim versions in Epic, and determines the appropriate corrective action based on predefined business rules.