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. Texas Medicaid (TMHP) won't accept a professional claim with more than 28 service lines, so any claim over the limit has to be split into multiple compliant claims, with the service lines distributed correctly across them, before it can be submitted. Doing that split manually is time-consuming and error-prone.

Automation Solution

This automation splits Texas Medicaid professional claims exceeding TMHP's 28-line maximum by cloning the claim in Availity, distributing the service lines across the cloned claims, and demanding the corrected claims in Epic for submission.