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Code in Flight Submission - Non VA Care Enhancements Phase III (BRD only)
Please use this identifier to cite or link to this publication: http://hdl.handle.net/10909/11074
Submitted by OI&T EPMO Lean Systems Engineering Open Source Coordination Office on 04-28-2015.
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

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