Problem Statement

Claims must be adjudicated against the plan's records, and the first step is matching each claim to the right member. Facets auto-matches members to claims, but when a piece of submitted information is misspelled or has changed, the system can't make the match, and it kicks to a representative who compares names and dates of birth manually. At claims volume this manual matching is slow and repetitive, and an unmatched claim can't adjudicate or pay until someone resolves it or sends it back for correction.

Automation Solution

This automation compares member first name, last name, and date of birth in the Geisinger Health Plan (GHP) system against the claim, matches members that Facets could not auto-match, and returns claims to the provider for correction when the identifiers don't match.