Automatic adjudication of all types of health insurance claims including reimbursement and direct-billing.
Uniform processing of different types of invoices (institutional, professional, allowance, etc) through the same claims engine yielding the same results.
Works with any (as well as multiple) procedure coding standard e.g. CPT, HICPS, local standards, home-grown lists, etc.
Automatic calculation of the amount payable to the provider based on contracted rates.
Automatic calculation of the insured member contribution based on the coverage rules of the insurance product.
Automatic calculation of allowance amounts based on product allowance schedules.
Flexible capturing of invoice line amounts through configurable, user-defined amount fields.
Powerful Review concept enabling manual review of suspended invoices.
Hundreds of data consistency and validation rules that the user can activate/deactivate as necessary.
User-defined rules (edits) that enable suspension of claims for review.
Sophisticated claim adjustment functionality including accurate automatic recalculation of affected claims.
Comprehensive Claims Reserves module that enables enforcement of different definitions of claims and reserving on multiple levels of the product structure.