A clinically-based claims payment software solution for payers that want to create and deploy flexible, automated rules to help improve payment accuracy, reduce appeals, and realize medical and administrative savings.

Increase Claims Payment Efficiency

Improve claims payment accuracy via automated alignment with CMS-sourced, state regulatory, and medical/payment policies. Increased transparency helps you address changes immediately.

Reduce unnecessary medical costs by staying current with evolving CMS policies and the recognized standards for medically appropriate care.

Streamline your claims adjudication process with clinically-supported claims editing. Apply edits in real time, at any point in your claim workflow. Automatically route claims to the appropriate department for review.

Enable payment innovation with simplified management of complex, mixed payment rules. Adjudicate claims in the context of your claims history, adjusting for specific provider contracts.

Improve your claims editing process by applying both standard industry edits as well as our growing body of advanced, clinically sound clinical editing rules, coupled with extensive rule customization flexibility.

Reduce system development costs and timelines by deploying your own policy changes across plans and regions, ensuring consistency and allowing for quick benefit recognition.

Streamline and Scale Claims Editing and Adjudication Processes

Address policy management needs with tailored clinical content

  • Targeted KnowledgePacks™ provide the clinical foundation of rules and logic necessary for intelligent claim edit results, allowing your organization to tailor ClaimsXten to address your unique needs.
  • Configurable Specialty Rx KnowledgePack provides medical guidelines-based content for automated maintenance and application of specialty drug policies during claims adjudication for both on- and off-label indications.
  • CMS Sourced KnowledgePack supports CMS guidelines on medically unlikely edits, durable medical equipment claims, and other coverage. This KnowledgePack can be applied to Medicare, Medicaid, and commercial business lines.
  • National and Local Coverage Determinations (NCD/LCD) KnowledgePack helps you implement evolving CMS rules for either professional or facility claims to commercial and Medicare lines of business, based on your payment policies.

Expand savings opportunities with targeted support

  • Facility KnowledgePack enables automated outpatient facility claims auditing with content on outpatient validation edits, bundling, and coverage using facility-based fields such as revenue codes and facility RVU. 
  • Waste and Abuse KnowledgePack helps you identify wasteful payments, billing errors, and abusive billing. Detect inappropriate billing of DME procedures, potential split claim billing of lab panels, and diagnosis mismatch.
  • Code Auditing Premium KnowledgePack addresses industry trends using historical claims data that crosses dates of services and providers. Edit appropriate billings of new patient, global, and component billing codes.
  • Cross Claims Plus KnowledgePack helps identify new savings opportunities across providers and service dates through broadly applied sourced and non-sourced content, reviewed and monitored by our clinical experts.

Extend ClaimsXten platform with optional modules

  • Our Content Manager module provides access to both default and unique content, as well as content supporting rule edits, to enable consistent payment policy management. Changes are preserved with an audit trail.
  • Our Policy Management module enables custom rules to support a unique plan design or specific regulatory requirements. Manage complex cases with maximized automatic claims adjudication, reducing manual claim review.
  • Our Clear Claim Connection module improves provider payment transparency by sharing claim edit rules, source information, and detailed clinical rationale for potential edits with providers via your health plan’s website.
  • Our Episode Manager module helps you integrate prospective payment models into your existing claims workflow. Identify episodes from a trigger claim within your system, and bundle all episode claims in near real time.

Providing Measurable Value

increase in claim auto-adjudication rates
reduction in appeals
savings rate of total paid dollars

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Additional Resources

Improve Medical and Payment Policy Management

ClaimsXten™ KnowledgePacks™ use a rigorous, evidence-based content development approach to payment policies and guidelines.

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Help Improve Claims Payment Efficiency, and Reduce Costs

Learn how ClaimsXten™ can help you effectively transition to a value-based payment model.

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