Multiple teams had to manually review rejected claims originating from different systems, leading to delays and human errors. The manual process of filtering through Excel and CSV files resulted in a growing backlog and an increased risk of SLA breaches, which in turn negatively impacted customer satisfaction and recovery rates.
Eclatprime implemented an automated solution that first filtered incoming rejected claims data. The system then transformed the data from Excel and CSV formats into cases within Pega, routing them to the appropriate team based on established business rules. Integration with member search engines and claims detail services ensured that all relevant information was automatically pulled into each case. Detailed, role-specific dashboards allowed auditors and managers to monitor progress and address exceptions promptly.
