SolutionS
Claims Editing Solutions
Find errors before they become denials. Apply precise, configurable edits that lift first-pass yield and cut rework.
Claims Editing validates and enriches incoming claims so they process cleanly on the first pass. The solution normalizes formats, verifies member and provider data, and applies configurable business, coding, clinical, and payment edits before adjudication. Rules check eligibility, coverage, duplicates, COB, NPI/Tax ID alignment, code validity and specificity, modifier usage, bundling and unbundling logic, medical necessity criteria, site-of-service appropriateness, frequency limits, and policy compliance. High-confidence fixes auto-correct common issues with full traceability, while true exceptions route to focused queues with clear reason codes and checklists.
Edit strategies are continuously tuned using denial analytics and provider feedback. Dashboards surface first-pass yield, top edit triggers, avoidable denials, and rework loops by LOB, provider, and code family. Targeted provider education closes recurring gaps, and simulation tools let teams test new edits against historical claims to quantify impact before deployment. Tight integration with intake, adjudication, and payment systems ensures consistent application of rules and clean, auditable outcomes.
Upfront Validation
Confirm eligibility, coverage, and core identifiers to prevent downstream errors and unnecessary denials.
Comprehensive Edit Library
Apply business, coding, clinical, and payment edits including code validity, specificity, modifiers, bundling, frequency, and site-of-service checks.
Configurable Rules & Policies
Tune thresholds, inclusions, and exclusions by line of business, plan, network, and benefit design without code changes.
Auto-Corrections with Audit Trails
Fix common issues such as missing modifiers or code pair conflicts when confidence is high, with full reason codes and versioning.
Exception Routing
Send only true exceptions to specialized queues with checklists, SLA timers, and collaboration to resolve quickly.
Duplicate & COB Controls
Detects duplicates and coordinates benefits accurately to prevent overpayments and rework.
Provider Feedback Loop
Share clear reason codes and education to reduce repeat errors and improve future claim quality.
Simulation & Impact Analysis
Test edits on historical data to forecast first-pass yield and denial impact before going live.
Analytics & Continuous Tuning
Monitor first-pass yield, top edits, denial drivers, and cycle time to refine rules and reduce waste.
Compliance & Transparency
Maintain governed rule catalogs, role-based access, and complete audit trails for reviews and accreditation.
Benefits
- Increase first-pass yield and reduce cost per claim with precise, targeted edits.
- Cut avoidable denials and rework by preventing errors before adjudication.
- Shorten cycle times through auto-corrections and streamlined exception handling.
- Improve provider experience with clearer requirements and fewer back-and-forth inquiries.
- Protect medical and administrative spend via duplicate detection and accurate COB.
- Adapt quickly to policy changes with configurable rules and governed releases.
- Make smarter decisions using simulation and denial analytics to guide tuning.
- Scale consistently across lines of business with a governed, auditable edit framework.