SolutionS
Claims Adjudication Solutions
Decisions that stand.
Apply consistent, rules‑driven adjudication to pay the right claim the first time.
Claims Adjudication executes benefit and policy determinations with precision and transparency. Incoming claims arrive from EDI and portals in standardized formats, then run through eligibility, coordination of benefits, plan accumulators, pricing, and medical policy checks to calculate allowed amounts and member liability. The process enforces plan rules and provider contracts, applies edits and fee schedules, and produces clear reason codes and correspondence so providers understand outcomes without back‑and‑forth. High‑confidence scenarios auto‑adjudicate, while true exceptions route to specialist queues with guided checklists and full audit history.
Operational controls keep the flow compliant and predictable. Role‑based permissions protect PHI, SLAs prioritize work by value and urgency, and audit trails capture every decision input and version. Dashboards track first‑pass yield, auto‑adjudication rate, adjustments, overturns, cycle time, and top denial drivers by line of business and provider segment. Tight integration with payment, remittance, appeals, and fraud/waste/abuse workflows ensures consistent application of policy and rapid resolution when issues arise.
Rules‑Driven Determinations
Apply benefits, medical policies, and provider contracts consistently to calculate allowed amounts and member liability.
Auto‑Adjudication at Scale
Maximize straight‑through processing for clean claims while routing only true exceptions to review queues.
Accurate Pricing & Contract Application
Leverage fee schedules, DRG/APC logic, and contract terms to price claims correctly the first time.
Clear Reason Codes & Correspondence
Generate standardized, comprehensible remits and notices that reduce provider abrasion and inquiries.
COB & Accumulator Integrity
Coordinate benefits accurately and update deductibles, copays, and out‑of‑pocket limits in real time.
Exception Management
Use checklists, collaboration, and SLA timers to resolve complex cases quickly and consistently.
Appeals & Adjustments Integration
Support first‑level and second‑level appeals with full traceability, and streamline adjustments with governed workflows.
Auditability & Compliance
Maintain complete decision logs, versioned rule catalogs, and role‑based access to satisfy reviews and accreditation.
Analytics & Tuning
Monitor first‑pass yield, auto‑adjudication rate, overturns, and cycle time to target improvements that lower cost per claim.
Interoperable by Design
Connect seamlessly with intake, editing, payment, FWA, and provider connectivity for end‑to‑end consistency.
Benefits
- Increase first‑pass yield and reduce cost per claim through high straight‑through adjudication.
- Shorten cycle times with precise pricing, contract application, and efficient exception handling.
- Lower avoidable denials and adjustments by enforcing benefits and policies consistently.
- Improve provider experience with clear remits, reason codes, and fewer rework requests.
- Enhance compliance with comprehensive audit trails and governed rule catalogs.
- Strengthen financial accuracy via reliable COB, accumulators, and contract terms.
- Gain visibility into drivers of overturns and rework to guide optimization.
- Scale confidently across lines of business with interoperable, rules‑driven operations.