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. A name or relationship mismatch between the claim and the payer coverage record trips an edit, but many of these are benign discrepancies that can be safely overridden, while others genuinely need a person. Reviewing every manually wastes time on the benign cases and slows down the ones that actually matter.

Automation Solution

This automation compares the name and relationship on the claim against the Epic coverage record from the payer, releases the claim when the discrepancy can be safely overridden, and forwards it for manual review when it can't, so staff focus only on the edits that require judgment.