Advanced Claim Management

An advanced claiming solution for payers that want to improve claim auto-adjudication rates and identify the most efficient path to process claims for a higher first-pass rate and lower costs.


EnhanceClaims Processing

  • Significantly improve processing cost-per-claim by reducing manual intervention in the claim re-pricing and/or adjudication process.
  • Support tangential claim adjudication processes with the ability to provide supplemental data.
  • Identify the most efficient path for healthcare claims to be delivered to the final claim adjudicator.
  • Reduce the time spent working pended claims with the ability to filter or reject transactions based on customer reference data.
  • Appropriately direct pre-adjudicated claims to/from PPO partners for repricing services prior to delivering to a customer for final adjudication.
  • Improve accuracy by validating, augmenting, replacing, and normalizing provider submitted data.

Improve Claim Auto-Adjudication Rates

  • Network edits & enhancements

    • Delivers claims efficiently. We validate, augment, replace and normalize provider-submitted data within a claim to improve auto-adjudication and reduce time working pended claims.
    • Accesses current and comprehensive payer information. Advanced Claim Management rejects or segregates claims using payer-defined criteria, as well as identifies and rejects duplicate claim submissions.
    • Applies client-specific pre-adjudication business rules to claims to reduce manual intervention in the adjudication process and improve processing cost-per-claim.
  • Claim routing service

    • Leverages hosted payer data to automatically route claims to/from PPOs for repricing services. Provides a claim to the payer that has already been repriced and is ready for final adjudication.
    • Identifies and automatically routes claims to other non-PPO entities besides the original destination for appropriate processing.
    • Creates multiple copies of claims to route to a given destination to support tangential claim adjudication processes.
  • Supplemental services

    • Render electronic data onto industry-standard paper claim forms. Deliver in an electronic (PDF) format to a customer.
    • Support supplemental reporting functionality to be delivered with or without the claim.

Our outcomes

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