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. When a COB vendor identifies that another payer was actually primary, the plan's records have to be corrected and any claims it paid in the wrong order revisited. Each flagged member needs the primary insurance updated in Facets, and the affected claims have to be sorted into true duplicates versus legitimate adjustments before reprocessing, so the plan recovers what it overpaid without disrupting claims that were correct. Doing this manually is detailed reconciliation work where a wrong duplicate call either misses a recovery or claws back a valid payment.

Automation Solution

This automation reviews COB vendor output, updates primary insurance in Facets where needed, and confirms true versus non-true duplicate claim handling for adjustment.