In the current system, processing Purchased Care claims requires a claims examiner to manually review and approve each claim. In contrast, organizations in the private sector use claims processing software to automatically adjudicate 60% to 80% of claims. “Automatic adjudication” is the use of computer software to examine claims and determine if they meet pre-determined standards for acceptance, or rejection. A “claim” may have more than one line item. The use of “claim” includes the review and auto adjudication of each line item found on a claim form.
The scopes of the enhancements are limited to modification of FBCS to incorporate automated business rules for adjudication.
• Automated business rules for auto-adjudication of claims