Enhance Claims Processing

Significantly improve processing cost-per-claim by reducing manual intervention in the claim

re-pricing and/or adjudication process.

Reduce the time spent working pended claims with the ability to filter or reject transactions
based on customer reference data.

Support tangential claim adjudication processes with the ability to provide supplemental data.

Appropriately direct pre-adjudicated claims to/from PPO partners for repricing services prior
to delivering to a customer for final adjudication.

Identify the most efficient path for healthcare claims to be delivered to the final claim
adjudicator.
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.