Is claim automation an effective way of adjudication?

Partially. There will always be some issue that someone needs to explain. Therefore "none of the above" is a good way to let people a way for a direct contact is a must.

Everything depends on the edits and complexity of policy. The ultimate goal of the adjudication is to be automated due to the number of claims.

 

Fraud and Abuse can be a department in the form of Analytics that can be a supporting part of automated claim adjudication. Major insurance companies trying to focus on insurance plans rather than thinking about the claims adjudication.

 

There is a simple and perfect example of Outpatient Code Edits from CMS and many more are maintained internally. Clearinghouse softwares are playing a vital role in automation.