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Provider Automation System

Business Issue:
The complexity of Provider data is an ongoing business challenge. Accuracy of data is critical to all functions including claims payment, customer service, and medical management. Erroneous information has a major downstream impact on claims payment accuracy/errors, encounter accuracy/errors as well as call center workload.

Provider Automation Solution:
The Provider Automation System was designed to improve the efficiency and integrity of information entered into the system. A database rules engine ensures all provider information is accurate and complete. It also allows for the import of large provider files from sources such as hospitals and large provider groups, instead of keying in each provider.

Once imported, the system filters the providers through the automated business rules engine to ensure all data is accurate and complete before importing into the provider system. This improves the accuracy of information while improving the efficiency of the network department.

ROI from Provider Automation:
"Just wanted to inform you about a 'quality initiative' that has been completed by the Provider Maintenance Department. We have terminated approximately 10,000 non-participating provider records that have not had any claim activity in a year and the record has not been established in the last 6 months.

"The provider automation application has helped us to accomplish this task. Without this new application this task could not have been completed with the current staff ratio. If we had to do this manually it would have taken us 86 man-hours vs. 10 man-hours.

"We will continue to utilize this process on an on-going basis. The provider automation application will also help up to meet the end of the year contract changes for all Lines of Business."

— AmeriHealth Mercy Health Plan

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