The Challenge
A prominent healthcare payer receives 780,000 inquiries annually from providers and members about claim statuses via email, fax, and post. Each inquiry requires a review of the current claim and any related claims as well as a personal response.
The Solution
Amitech, a Naviant Company, collaborated with this payer to create a solution integrating UiPath’s Communication Mining with RPA to automate claim status inquiries. Machine learning models read and understand email inquiries, after which the system extracts the claim status and generates a templated response. Related claims and inquiries are checked for additional information. If the bot is unable to determine the status, the inquiry is rerouted to a human queue. This automation enhanced efficiency, reduced response times, and improved member satisfaction.
Implementation
The process for implementation is as follows:
- Customer Service Warehouse (CSW): UiPath Communications mining discovers the intent of inquiries housed in the CSW.
- P8 (Member Management System): A bot performs validations using data, including medical records, stored in P8.
- PDF: Relevant information is copied and attached as a document to the claim status inquiry. The bot then formulates a response based on its validations.
