checkmark in a box iconClaims Integrity for Payers

A proven approach combining technology and analytics with a team of medical professionals who bring unparalleled depth of insight and experience to the cost management process.

Zelis Healthcare offers the tools, technologies, and expertise you need to ensure that you pay the appropriate cost on every claim, every time. Our integrated system enables multiple layers of review that identify and correct erroneous claims, saving you money and reducing your liability. The Zelis approach combines technology and analytics with a team of medical professionals who bring unparalleled depth of insight and experience to the cost management process.

Our comprehensive claims integrity solution encompasses:


Claims Editing

Zelis uses leading technology and high-touch process evaluating claims, determining billing and coding accuracy by cross-referencing claims history and claims data. We produce fast and accurate results that are fully aligned with industry-recognized guidelines, ever-changing compliance requirements, and each client’s customized needs. All of this is done before any payments are made.

  • Adherence to industry-recognized edits and guidelines to ensure compliance with payment policies
  • Ability to configure and customize edits based on your payment policies, to detect most overbilling occurrences and ensure claim accuracy
  • Flexible appeals options: Zelis can manage all appeals or a portion, depending on your preference

Clinical Bill Review and Audit

Zelis Healthcare professionals focus on chart audits to uncover errors and inappropriate charges. We perform a cost analysis and compliance review while ensuring adherence to plan guidelines. Zelis healthcare professionals focus on chart audits to uncover errors and inappropriate charges. We perform a cost analysis and compliance review while ensuring adherence to plan guidelines.

  • Line-by-line chart audit with focus on clinical accuracy, cost-to-charge analysis, and plan policy adherence, resulting in secured savings
  • Clinical expertise with specialty peer reviews offering concrete findings based on industry-recognized FDA guidelines and standards that focus on ensuring medical necessity
  • Enhanced chart validation and assessment of claim itemization to identify bundled charges and supplies that are appropriate for additional claim cost reduction
Zelis Healthcare is providing the tools and strategies necessary for our industry to move forward in a powerful and proactive manner. They brought tremendous value to our company and our clients, enabling us to become more productive, efficient, knowledgeable and successful.
TPA client for over 10 years

Out-of-Network Services

We leverage a multiple-layer approach to out-of-network claims by using our data, integrity offerings, benchmarks and scalable technology to determine the “net cost of the claim.” This allows us to evaluate the claim from a “cost-up” perspective. In addition, by using multiple data points, we drive successful negotiations with signed provider agreements and assurance that plan members aren’t balance billed.

  • Leverages contracted solutions to reduce the plan and employee’s liability on out of network claims
  • Performs expert negotiations through an array of benchmark and provider historical data to determine rational payments for non-par claims
  • Empowered by robust technology to ensure adherence to strict turnaround time requirements
  • Flexible options available for referenced-based pricing that support the market needs through proprietary fee schedule pricing tools designed to control plan costs
  • Medicare based pricing solutions for plans who wish to use alternatives to IN or OON cost containment products
  • Offered in conjunction with RBP programs, Zelis’ claim settlement services provide balance billing support through its post-payment settlement program
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Through our Out-of-Network Services offering we were able to provide significantly reduced rates for thousands of medical providers.

Read the Case Study