Problem Statement

Claims that have already adjudicated often need corrective adjustments against payer rules, and applying those rules by hand at volume is slow and inconsistent. Emergency claims are a rules-heavy example: a benefits analyst has to open each claim from the work queue and walk it through the ER adjustment logic line by line, deciding which lines meet the criteria and overriding the type-of-service and tier values accordingly. The logic is detailed and repetitive, and an inconsistent or skipped adjustment flows straight through to an incorrect payment.

Automation Solution

This automation retrieves Emergency claims in Facets, applies the ER adjustment logic line by line, overrides the qualifying lines' Type of Service and Variable Component Tier values per the rule set, and saves the claim.