Problem Statement

A health plan should pay only when it's the responsible payer, and only after any primary payer has met its obligation. Keeping that straight depends on accurate coordination-of-benefits data - who's primary, what's active, and through what dates - but that information constantly drifts as members gain, lose, and change coverage. Reconciling it manually against payer reports and member records is slow and error-prone, and when COB data is wrong the plan pays as primary when it shouldn't, misses recoverable dollars, or denies claims it actually owes. The CAQH COB report is a key source for keeping this current, but its findings only matter once they're reconciled into the plan's system: each member's payer primacy, carrier listing, and termination dates have to be compared against Facets and the right correction applied. Working the report line by line manually is slow, and stale primacy or term dates left uncorrected lead directly to claims paid in the wrong order.

Automation Solution

This automation uses the CAQH Coordination of Benefits report to update member payer primacy, carrier listing, and termination dates in Facets and determines the correct action for each.