Software

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.

 

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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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Fact Sheet

Get EOB data from multiple payers via Payer Data Exchange

Fact Sheet

Get EOB data from multiple payers via Payer Data Exchange

Learn how you can access essential EOB data from multiple payers in a single, standardized format via a single, secure connection with Payer Data Exchange.

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Fact Sheet

Pre-Care Alert™ for Advocates, by Payer Data Exchange™

Fact Sheet

Pre-Care Alert™ for Advocates, by Payer Data Exchange™

Learn how Payer Data Exchange can proactively alert healthcare advocates about planned care for members before it happens instead of after.

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Fact Sheet

Integrated Repricing Network Reduces Costs

Fact Sheet

Integrated Repricing Network Reduces Costs

Discover how to maximize savings on out-of-network claims and seamlessly connect with 70+ PPO networks through an Integrated Repricing Network.

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