Zelis has reviewed more than $140 billion in claims, combining leading-edge technology and superior clinical expertise to maximize claims cost savings by uncovering and reducing provider errors, waste and abuse through claims editing, clinical bill review, dialysis savings and support and out-of-network negotiations.

The more you buy, the more you save. By utilizing one vendor for all of your cost management and payments solutions, you’ll realize savings by reducing the cost of complexity associated with managing multiple vendors while improving the administrative efficiency across the entire life cycle of a claim.

Claims Editing

Combining advanced technology with expert insight to cross-reference claims history and claims data, Zelis Claims Editing identifies superior billing and coding accuracy errors.

The Zelis application of 40+ editing categories to more than 16 million claims each year results in multiple millions of code combinations and cost-minimizing results that are fully aligned with industry-recognized guidelines and ever-changing compliance requirements.

Clinical Bill Review & Audit

The Zelis approach to Clinical Bill Review & Audit utilizes a team of specialized clinicians to audit inpatient and outpatient claims to uncover coding errors and inappropriate charges and includes a full scope clinical and financial cost analysis and compliance review that adheres to plan policy requirements and billing standards. Zelis’ has conducted approximately 200,000 reviews and audits, resulting in more than $300 million in savings.

Specialty Clinical Audits

Zelis Specialty Clinical Audits is a customizable audit program designed to address costly claim drivers that may typically be considered carve outs in health plan network contracts. This solution is managed through an integrated strategy driven by proprietary claim selection technology, clinical algorithms, an intense clinical audit and a unique approach to episode of care management.

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Dialysis Savings & Support

Zelis Dialysis Savings & Support can effectively identify and manage claims before, during and after treatment has begun. Utilizing multiple methods to secure the deepest discounts for all claim scenarios. We don’t simply use automated software to arrive at claim savings. We employ a variety of hands-on approaches to controlling high-cost dialysis treatment.

Industry's most comprehensive approach

  • Proprietary plan document verbiage to limit claim exposure
  • Prior authorization services to help intervene before treatment
  • Data mining to identify patients before treatment starts
  • Negotiated settlements with executed letter of agreements
  • Proprietary dialysis pricing data
  • Appeals support

Out-of-Network Services

When claims errors, waste and abuse cannot be resolved with providers through Claims Editing and Clinical Bill Review and Audit, the Zelis Out-of-Network Negotiations team negotiates the claim with the provider by applying 14 years of Zelis claims history with industry claims cost benchmarks to the negotiation of claims pricing. Our process has delivered a 90% provider claims payment acceptance rate for all out-of-network claims dollars with less than 5% balanced billing.