Under which circumstance should Automated Reviews be conducted?

Automated Reviews are specifically designed to streamline the process of identifying and resolving consistent billing issues, particularly in circumstances where there is certainty about an overpayment or underpayment. This means that when clear evidence indicates that the payment amount made does not align with what is owed—whether too much or too little—the Automated Review process can be efficiently utilized to assess these discrepancies.

This approach allows for accurate and timely corrections, ultimately improving the financial integrity of claims processing. Conducting an Automated Review under these circumstances helps to minimize manual intervention and speeds up the resolution process, ensuring that the correct amounts are billed and paid.

In contrast, other scenarios such as uncertainty about a claim or after a claim has been denied may require different approaches, such as additional manual review or clarification processes, which may not fall under the Automated Review protocol. Performing Automated Reviews every time a claim is processed could lead to unnecessary reviews on claims without discrepancies, thus not being an efficient use of resources.