A rules-based claims payment solution for payers who want help to improve payment accuracy, reduce appeals, and reap both medical and administrative savings.


6features to help boost claims payment accuracy and efficiency

Optimize claims payment accuracy

Support accurate claims payments by automatically verifying alignment with all relevant contract, regulatory, and CMS policies.

Reduce unnecessary medical costs

Minimize overpayments by adhering to current CMS policies and recognized standards for medically appropriate care.

Streamline your claims adjudication process

Drive operational efficiency by automatically routing claims to reviewers who can apply clinically supported edits at any point in your claims process.

Enable payment innovation

Flexibly adapt your claims adjudication to changes in policies and contracts by simplifying management of even the most complex mixed payment rules. 

Improve your claims editing

Bring a new level of precision to claims editing by applying a combination of standard industry edits, our growing library of advanced clinically based editing rules, and flexible rule customization.

Shrink system development costs and timelines

Helps save time and money by expediting consistent deployment of policy changes across plans and regions.

What's included

  • Clinical content for better policy management

    • Customizable editing rules and logic
    • Guidelines for specialty drug policies
    • CMS guidelines for coverage, claims, and edits
    • National and local coverage determinations
  • Support for expanded savings

    • Automated outpatient facility claims auditing
    •  Automated detection of waste, errors, and abuse
    • Easy global editing of billing codes
    • Expert content for identifying new savings opportunities
  • Additional platform modules

    • Content Manager for easy access and change audit trails
    • Policy Management for designing and automating complex custom rules
    • Clear Claim Connection for sharing rules and edit rationales with providers
    • Episode Manager for integrating prospective payment models in existing claims workflows


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