Intelligent Health Plan Solutions for Modern Payers
Transform your Health Plan operations with our comprehensive suite of customized intelligent solutions. From AI-powered claims processing to program integrity and member support services, we deliver end-to-end solutions that optimize accuracy, efficiency, and member satisfaction. Our deep healthcare expertise ensures solutions that address both current challenges and future needs.
AI-Powered Claims Adjudication
Advanced Claims Management Tools
Custom Health Plan Solutions
Program Integrity Solutions
Payment Accuracy Services
Call Centers & Chat Support
Business Process Optimization (BPO)
Configuration & Benefit Administration
Ensure seamless setup and management of benefit plans, pricing structures, and claims processing rules. Automate contract administration, fee schedules, and external claims editing to improve accuracy and compliance.
Design, configure, and manage complex benefit plans across multiple payers and plan types with accuracy and speed. Streamline updates, pricing, and rule setups to reduce errors and ensure compliance.
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Key Capabilities:
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- Benefit Plan Build & Adjustments – Configure new plans or update existing ones with flexible rule management.
- Multi-Payer & Multi-Plan Support – Handle diverse payer requirements and plan variations with ease.
- Pricing & Contract Setup – Define pricing logic, set up provider contracts, and manage fee schedules.
- Code Set Management – Maintain CPT, ICD, HCPCS, CARC, RARC, and other standard code sets.
- External Grouper/Pricer Integration – Integrate third-party pricing engines for accurate claims calculation.
- Claims Editing Rules – Configure external claims editing logic to catch errors before adjudication.
Set up and manage provider contracts, reimbursement terms, and fee schedules with precision. Ensure consistency across systems and streamline updates to support accurate claims processing and regulatory compliance.
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Key Capabilities:
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- Provider Contract Setup & Management – Define contract terms, reimbursement rules, and network affiliations.
- Fee Schedule Administration – Maintain and update pricing schedules for services, procedures, and provider types.
- Multi-Payer Contract Handling – Configure and manage contracts across different payers with built-in flexibility.
- Automated Updates & Version Control – Implement bulk updates and maintain historical versions for audit readiness.
- Integration with Claims & Pricing Engines – Ensure contract terms are reflected accurately during adjudication.
- Code Mapping & Exception Handling – Align code sets with contract logic and manage pricing exceptions effectively.
Configuration & Benefit Administration
Ensure seamless setup and management of benefit plans, pricing structures, and claims processing rules. Automate contract administration, fee schedules, and external claims editing to improve accuracy and compliance.
Provider & Member Management
Ensure seamless coordination between providers and members with automated credentialing, enrollment, and eligibility verification. Improve operational efficiency with streamlined contract management, PCP assignments, and communication tools.
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Provider Credentialing & Network Management – Automate credentialing, contract administration, and network optimization.
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Member Enrollment & Eligibility Verification – Ensure accurate member onboarding and real-time eligibility validation.
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PCP Assignments & ID Card Fulfillment – Assign primary care providers efficiently and manage ID card distribution.
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Automated Correspondence & Demographic Updates – Streamline communication and maintain up-to-date member and provider records.
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Regulatory Compliance & Audit Readiness – Ensure adherence to industry standards with automated compliance tracking.
Back-Office Operations
Enhance efficiency and accuracy with streamlined customer service, financial management, and reporting solutions. Automate workflows, optimize financial transactions, and ensure compliance with real-time insights and data-driven decision-making.
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