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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.
