Auggie’s General Review Rules for Claims
Auggie, our AI Machine Learning genis exercises a meticulous approach to claim processing, only advancing claims to the payor when he is at least 98.4% confident they will be approved. At this stage in his career, Auggie understands that his professional reputation is paramount. He is committed to maintaining the highest standards of accuracy and reliability, knowing that trust from the service industry is critical—not only in his current role, but also as a foundation for his continued professional development.
Below are many examples of claim scenarios currently held in Auggie’s review queue, for various manufacturers, pending final verification by highly skilled JusrPressOne claims administrators
- Authorization Numbers: Claims containing an authorization number are flagged for review to ensure labor details align correctly and that the authorization format adheres to standards.
- Warranty Eligibility: If more than 365 days have passed between the unit’s purchase date and the repair receive date, the claim is stopped for an agent to verify extended warranty coverage or identify a missing authorization.
- Part Verification: All part numbers are validated through authorized parts distributors. If a part number lacks a valid description or cannot be located, the claim is held for further investigation.
- Recall Claims on Serial Numbers: If a repair center submits a claim for a serial number that has a prior claim on file, the claim is held to determine whether the new repair is due to a different cause or utilizes different parts.
- Sealed System Repairs: In cases involving complex sealed system repairs (e.g., “No Cool” issues or parts such as driers, compressors, or evaporators), claims are stopped to confirm that appropriate additional labor charges are included.
- Stock Claims: Claims marked as stock are reviewed to verify that the associated customer is, in fact, a business entity (e.g., store or apartment complex).
- Date Sequencing and Timeliness: Claims are verified for chronological consistency. If a claim is submitted more than 45 days after repair completion, it is held to comply with payor submission deadlines.
- Authorization Numbers: Claims containing an authorization number are flagged for review to ensure labor details align correctly and that the authorization format adheres to standards.
These examples simply represent just a subset of the checkpoints within Auggie’s AI comprehensive Machine Learning quality control process. As his expertise grows and his confidence deepens, some of these validations may be selectively bypassed based on the trustworthiness of specific repair centers and the policies of particular payors.
Learn more about Auggie’ successful claims processing tips and techniques at https://claimworks.ai/news/
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