Problem Statement

Not every Medicare claim in the follow-up queue is ready to be worked. A claim still moving through the MAC's editing system shows a pending status and simply hasn't finished processing yet. Medicare's guidance states that a claim in this state should be left alone, since resubmitting or acting on it creates a duplicate claim. When staff open these pending claims anyway, they not only spend time on accounts that can't be worked, they risk introducing the duplicates that follow-up is trying to prevent. Sorting the truly workable claims from the still-processing ones manually is low-value triage that consumes time and invites error. This automation checks Medicare claim status and defers claims still processing in the MAC's editing system. It routes only finalized claims to the staff work queue, so staff open only claims that are ready to work and pending claims are left untouched until they finalize.

Automation Solution