The system displays prospective matches to knowledge workers in order of the likelihood of the match, who then identify the correct provider. The claim payment system determines whether a claim can be paid, and how much to pay, if there are no inconsistencies between six key data items associated with the claim. Adjudication of pended claims. The adjudicator can access the mainframe system for a claim history or the image system for an image or, for electronic claims, a fabricated representation of the original claim. The adjudicator either approves the claim for payment, specifying the proper amount to pay, generates correspondence requesting additional or clarifying information, or generates correspondence denying the claim.
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The Design Problem Design a work routing system that routes health claims through the various stages of the adjudication process. The process manager modifies routing rules for a Dental claims, one of a number of claim types. The process manager has the option of having the new routing rules apply only to newly received claims, or to claims already being processed. The system automatically identifies any claims that have reached a state under the old process that is inconsistent with the new process. The system administrator access the workflow system to determine whether all work objects are accounted for.