Claims QA Process

Purpose and Scope

This guide documents the quality assurance process for claims adjudication. It covers:

• Examiner roles and the release authority for each

• Training and advancement requirements for the New Yuzer role

• The pre-pay audit workflow for trainees

• The post-pay monthly audit workflow for associates

• The high-dollar claim review process

• The Audit Tracker, where audit results are recorded

Examiner Roles

The Yuzu claims team assigns each examiner a role. The role controls which claims an examiner can release, meaning finalize the claim so that payment (or a denial) goes out without further review, and how their work is routed for QA before that happens.

New Yuzer Training and Progression

Timeline

1. Two weeks of classroom training: The new examiner works side by side with a trainer learning the basics of healthcare and insurance.

2. 100% pre-pay audit: After classroom training, the examiner begins processing live claims, but every claim is routed to QA before release. To date, every new Yuzer has remained at 100% audit for a minimum of six weeks.

3. Stepped release: The examiner works through dollar thresholds and audit sampling levels until they are fully released from audit for all claim types.

4. Promotion to Associate: Once released on all claim types, the examiner is promoted to the Associate role.

End to end, the process from first day to full release typically takes 8 to 12 weeks. There is no fixed calendar date for release. An examiner is released when the team is confident they can correctly handle any claim placed in front of them and knows the escalation path when something unfamiliar comes up.

Training channel

While in the New Yuzer role, examiners have a dedicated training channel. Only leads answer questions in this channel, so that trainees receive consistent and correct information.

Order of claim types

Claim types are introduced from simplest to most complex, and release is tracked separately for each type:

1. Professional, in-network

2. Professional, out-of-network and other variations

3. Institutional

Institutional claims are always introduced last because they are more complex and tend to involve higher dollar amounts (See Dollar thresholds below).

Dollar thresholds

A dollar threshold is the maximum amount a claim can pay out for the examiner to be allowed to release it without additional review. Thresholds are based on the paid amount, not the billed charges. A claim billed at $20,000 that pays $1,800 falls under a $2,500 threshold.

Within the New Yuzer role, release authority steps up through the following paid-amount thresholds:

$0 → $2,500 → $7,500 → $15,000 → $40,000

An examiner starts at $0, meaning nothing can be released regardless of amount. Each step up allows them to release claims paying up to that amount, subject to the audit sampling level for that threshold (see Audit sampling levels below). Claims paying above the examiner’s current threshold are always audited at 100% before release.

Thresholds are tracked separately for each claim type, so an examiner may be released on professional claims up to $40,000 while still limited to $2,500 on institutional claims.

$40,000 is the maximum for any non-lead examiner. Only leads process claims paying above $40,000 (see High-Dollar Claim Review).

Audit sampling levels

Audit volume steps down as the examiner demonstrates proficiency. For each claim type, sampling always moves in this order:

1. 100% of claims audited

2. 50% of claims audited

3. 25% of claims audited

4. Fully released from audit for that claim type

Sampling is tied to the examiner's current dollar threshold. Claims paying at or above the examiner's approved threshold are always audited at 100%. Claims below the threshold are audited at the examiner's current sampling percentage.

Example: An examiner approved to release up to $2,500 and currently at 50% sampling. Claims paying $2,499 or less are audited at 50%. Claims paying $2,500 or more are audited at 100%.

The assumption behind sampling is that it is representative. If 50% of an examiner's claims are audited and one error is found, the working assumption is that there are roughly two errors in the full set.

Advancement criteria

To move to the next dollar threshold or the next sampling level, an examiner must pass audit for a minimum of six consecutive processing days. Once moved, the count resets and they need six more consecutive passing days at the new level before advancing again.

Judgment is applied in limited cases. A single failed day caused by a system error, or by multiple instances of the same mistake on one claim, may not reset the count.

Advancement is not based on score alone. The review team also looks at the type of findings. A pattern of repeatedly forgetting one small step (for example, a remark code) is treated differently from findings that suggest the examiner does not understand the adjudication.

New Yuzer Audit Workflow (Pre-Pay)

All trainee audits are pre-pay: the claim is reviewed and corrected before any payment goes out. The workflow is built into the portal, and each finding is also logged on the Trainee Audit Tracker Report (See Recording Results: The Audit Tracker).

1. Trainee processes the claim: A banner on the claim indicates it is blocked by QA. When the trainee reaches the pay tab there is no release button, only a ‘Submit to QA’ option. The claim routes automatically to the QA queue.

2. Claim lands in Pending Review: Leads and the QA lead work this queue. (In the work queue, a new Yuzer's claims show as Pending Review; an associate's claims show as View QA.)

3. Auditor grades the claim: The auditor selects Pass or Fail. If Fail, the auditor must select Financial or Procedural, mark the error category, and enter notes describing what needs to be fixed.

4. Fails cannot be released: If anything on the claim is marked Fail, the portal removes the option to release and forces the auditor to return the claim to the examiner.

5. Claim moves to the examiner's ‘Action Needed’ queue: The audit notes appear directly on the claim. The examiner reprocesses the claim and submits it back to QA.

6. Auditor re-reviews: If the claim now passes, the auditor releases it. If the same error is still present, it is returned again and logged as a repeat error.

7. Audit history is retained: Every claim has a ‘Review History’ button showing all notes exchanged between the auditor and the examiner, even after the claim is finalized. A claim with no findings shows as released after approved decision.

New Yuzers are in training, so audit feedback is returned quickly. Immediately following classroom training, the goal is to return audits within 24 hours of processing so trainees can correct mistakes while the claim is still fresh. As the examiner progresses through audit levels, the goal is to return all audits within one week of processing.

Although new Yuzers cannot release claims, any examiner in a higher role can open a new Yuzer's claim and release it if needed (e.g., if the trainee is out). The QA banner remains on the claim. This keeps the block from stopping production entirely.

Associate Monthly Audit Workflow (Post-Pay)

Once an examiner is in the Associate role, pre-pay audits stop and they move to a monthly post-pay audit. These claims have already been paid, so the goal is accuracy of the finding before anything is sent back.

Random Sample

• On the first of each month, a random sample of 30 claims from the prior month is pulled for each associate.

• The sample is 30 regardless of volume. An examiner who processed 40 claims and one who processed 200 are both audited on 30.

The target is to complete the prior month's audits within the current month (for example, all August audits completed by the end of September), so the team is never more than one month behind.

Two-level review

1. Primary review: The QA lead reviews all 30 claims using the same criteria as trainee audits: Classification into Financial, Procedural, or FYI; overpayment or underpayment; error categories.

2. Secondary review: A manager, supervisor, or lead reviews every finding to confirm they agree. This step exists specifically because the claims are post-pay. The team does not want to send an examiner a finding that is not a true error.

3. Results shared: Once all 30 claims have passed both reviews, the results are shared with the examiner.

Examiner response

The examiner reviews their audits in the portal. For each failed claim they can open the finding and see the criteria. Because the claim has already been paid, the examiner cannot simply reprocess it. Instead they agree or disagree with the finding:

• Agree: The examiner adjusts the claim, the correction is made, and the finding stands.

• Disagree: The finding goes to the examiner's supervisor for additional review and discussion. Disagreeing does not remove the finding by itself; the examiner is asked to explain why.

  • If the finding is still unresolved after this process, it gets escalated to the VP of Claims who makes the final decision.

High-Dollar Claim Review

A final layer of QA applies to high-dollar claims. The threshold is $40,000 paid, based on stoploss carrier requirements (e.g., TPAC and ARLO require review of any claim paying over $40,000 before release).

System flag

The system places a High-Dollar Claim Review flag, in Draft status, on every claim with billed charges over $40,000. The flag stops the claim from auto-adjudicating and auto-paying.

Processing

1. The examiner processes the claim.

2. If the claim pays less than $40,000: The examiner moves the High-Dollar Claim Review filing from Draft to Canceled. No further review is required.

3. If the claim pays $40,000 or more: The filing stays in Draft and the claim routes to a lead (the high-dollar claim processor).

Stoploss submission

If the claim must go to the stoploss carrier under that carrier's rules:

1. The lead moves the filing from Draft to Pending. Pending status continues to hold the claim from auto-payment and enables attachments on the filing.

2. The lead attaches the required documents:

   • Completed high-dollar claim form

   • Copy of the claim

   • Copy of the pre-cert (required in nearly all cases)

3. The lead sends the stoploss carrier a link to the high-dollar filing so the carrier can review all materials in one place.

4. Once the carrier approves, the lead marks the filing Completed.

5. A lead, the claims manager, or the VP of claims releases the claim.

Claims sent to a stoploss carrier are also recorded on the stoploss log.

Recording Results: The Audit Tracker

The Claims team has an Audit Tracker where the QA team records every audit finding and the daily and monthly results for each examiner. The portal handles the audit itself: routing the claim, grading it, and sending notes back to the examiner. The tracker is where those results are logged in a structured way so the team can see trends, calculate scores, and decide when an examiner is ready to move up.

The Audit Tracker has four main reports:

Trainee Audit Tracker

Each row on this report is one finding, and the row tells the full story of that finding from start to finish. Every audit finding is classified into one of three types:

• Financial: Anything that impacts payment, including the member's responsibility. A claim that pays $0 can still carry a financial finding, for example if the full amount was applied to deductible when it should not have been. For every financial finding, the auditor also records:

  • Whether it was an overpayment or an underpayment

  • The dollar amount of the error: what the claim billed, what it paid, and how far off the payment was

• Procedural: The claim outcome was correct, but the process was not. Examples:

  • Missing remark code

  • Claim denied for the wrong reason, but correctly denied

• FYI: No impact on how the claim was processed, but a habit the team wants the examiner to build. Examples:

  • Missing claim note explaining how the claim was processed

  • Note not connected to the pre-cert

In addition to finding type, each finding is tagged with the area where the error occurred. The list of Error Categories include:

• Benefit Tier

• Repricing

• Benefit Category

• Cost Share

• Other (catch-all for issues that do not apply to every claim; the specifics are described in the audit notes)

It then captures the feedback sent to the examiner (with any repeat errors highlighted) and how the finding was closed out: whether a second reviewer confirmed it, whether the examiner agreed, and the final outcome of the claim, usually that it was corrected or adjusted.

Trainee Summary

This report is each trainee’s performance summarized day by day. Where the Trainee Audit Tracker logs every individual finding, this is the scorecard: one row per trainee per processing day, grouped by date. This covers:

• The audit itself: how many claims were audited that day, who audited them, and when the audit was completed

• Findings rolled up: totals by claim type (institutional vs. professional), by finding type (financial, procedural, FYI), and by error category, with a short notes column calling out the themes behind the numbers

• Review and closeout: whether secondary review was completed, how many findings were overturned, and any additional notes

• The score: total correct and percent correct for the day, highlighted in red when it falls below the passing score

This report is what the review team uses to confirm the six consecutive passing days needed to advance (see Advancement criteria).

Monthly Audit Tracker and Monthly Summary Reports

These follow the same structure as the trainee reports, with one row per finding and a monthly roll-up per associate. The monthly audit process itself is described under Associate Monthly Audit Workflow (Post-Pay).