Out-of-Network Solutions
Balance savings and provider acceptance with AI-assisted, defensible out-of-network claims pricing.
Claims Optimization with Zelis®
Maximize savings on every claim with pricing, payment integrity and out-of-network solutions.
Cut Through Claims Complexity
AI-enabled cost containment solutions designed to optimize every claim for accuracy and savings without adding abrasion.
Manage rising claims costs
Unify pricing, payment integrity and OON (out-of-network) programs to unlock more savings.
Reduce provider friction
Transparent edits, pricing and support reduce disputes and rework.
Sustain savings over time
Use transparent edits, expert review and defensible pricing logic.
Minimize vendor sprawl
Replace scattered tools with a connected cost-containment ecosystem.
Zelis Claims Optimization Capabilities
In-Network Solutions
Optimize contracted and non-contracted claims with benchmark-based pricing.
Payment Integrity Solutions
Reduce inaccurate payments with claims editing and complex claims review.
Zelis Intelligent Pricing Platform®
One ecosystem that connects AI, automation and expert oversight to optimize every claim end-to-end.
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How One Payer Used Market-Based Pricing to Drive Out-of-Network Savings
See how a regional healthcare payer expanded ERS market-based pricing to grow out-of-network savings while keeping provider disputes low.
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Better Outcomes Before IDR: A TPA Case Study in NSA Performance
Explore how to use AI and automation improve healthcare claims management and how collaborating with experts can help.
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Proven Savings with SmartShopper
Discover the findings of the Wakely report, highlighting savings of $552 through SmartShopper participation and care transparency.
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Zelis Health Bill Assist℠ helped cut $52,000 in medical costs
Discover how expert advocacy and support from Zelis Health Bill Assist helped one member save $51,000 on an out-of-network medical bill.
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Claims Optimization Resources
Reimagining P&C Claims Performance Webinar
Learn how P&C insurers can modernize medical payments, reduce manual work, accelerate claims workflows and improve claimant and provider experiences.
How One Payer Used Market-Based Pricing to Drive Out-of-Network Savings
See how a regional healthcare payer expanded ERS market-based pricing to grow out-of-network savings while keeping provider disputes low.
Payment Integrity Vendor Selection White Paper
See how US healthcare payers can choose the right payment integrity vendor, reduce provider abrasion and improve retained savings with smarter claims strategy.
Frequently Asked Questions About Claims Optimization
Payers can reduce out-of-network claim costs by using a layered pricing strategy that balances savings, provider acceptance and member experience. Zelis helps payers apply configurable out-of-network pricing, network pricing, negotiations and reimbursement strategies to route claims to the right savings opportunity. This approach supports more defensible pricing decisions, helps mitigate balance billing risk and creates greater transparency across out-of-network claim workflows.
Reference-based pricing helps payers set reimbursement limits using predefined pricing benchmarks instead of relying solely on traditional PPO network discounts. Zelis Open Access Pricing supports reference-based pricing programs with pricing technology, provider engagement, member advocacy and direct provider agreements. This helps payers manage rising healthcare costs, expand provider access, reduce billing disputes and create a more predictable cost containment strategy for employer groups and members.
Payers can build stronger networks by using data-driven insights to assess access, identify provider gaps, compare competitive network performance and select the right mix of primary, wrap and supplemental networks. Zelis network solutions help payers build, manage and optimize high-performing networks while expanding provider coverage and supporting member savings. This helps reduce out-of-network exposure, improve access and strengthen long-term network performance.
Health plans can improve claims pricing accuracy by using configurable pricing logic, contract modeling and transparent claim-level process trails. Zelis helps payers price in-network claims, compare provider rates to public benchmarks, analyze contract performance and apply advanced pricing methodologies across plan types. With clear visibility into formulas, edits and reimbursement logic, payers can reduce confusion, strengthen provider negotiations and make more informed pricing decisions.
Payers can manage No Surprises Act and independent dispute resolution (IDR) exposure by applying defensible out-of-network pricing, transparent reimbursement logic and consistent claim documentation. Zelis helps payers support NSA-related workflows with pricing strategies, provider negotiation support and claim-level insights that help reduce disputes, improve offer defensibility and manage the administrative burden of IDR.
Pre-payment integrity helps health plans identify potential claim errors before payment is made. Compared with post-pay recovery, a pre-pay approach can reduce administrative burden, limit provider abrasion and help prevent overpayments earlier in the claims process. Zelis supports both pre-pay and post-pay workflows, using post-pay insights to strengthen pre-pay claim review logic over time.
Payment integrity focuses on paying claims accurately by identifying errors, waste, incorrect coding and overpayments. Claims optimization is broader. It brings together payment integrity, claims pricing, in-network and out-of-network solutions to help health plans improve savings, reduce friction and manage claims more efficiently.
Claims optimization helps health plans increase savings by connecting payment integrity, claims pricing, in-network and out-of-network strategies. Zelis helps plans identify savings opportunities across the claim lifecycle while supporting accuracy, transparency and provider collaboration.
