ClaimPass®
Optimize pricing with dynamic market intelligence, public benchmarks and risk logic.
Zelis® Out-of-Network Solutions
Route every claim automatically, accurately and with your plan's goals built in.
What Sets Zelis Out-of-Network Pricing Apart
AI-assisted optimization
Dynamic routing balances compliance, risk and savings within client thresholds for every available channel.
Full customization
Set rules by individual employer group, service type, claim type or member for flexible, plan-specific control.
Negotiation and settlement support
Navigate NSA and non-NSA provider negotiations with defensible out-of-network pricing logic.
Inquiry rate reflects claims based on Zelis pricing
Zelis Out-of-Network Solutions
Health Bill Assist®
Improve your member experience with expert out-of-network balance bill navigation.
NSA Claim Advantage℠
Reduce NSA dispute risk with defensible pricing, negotiation support and claim insights.
-
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.
Read more -
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.
Read more -
How one health system manages high payment volume in half the time
See how one large health system cut payment reconciliation time in half and streamlined high-volume payments with Zelis.
Read more -
From $156K to $430: A Health Bill Win That Earned Member Trust
Discover how expert advocacy and support from Zelis Health Bill Assist helped one member save $51,000 on an out-of-network medical bill.
Read more
Explore All Out-of-Network Resources
Insights for Every Role: Using Claims Data to Stop Denials
Learn how providers can use claims data to prevent denials, accelerate cash flow, and improve financial performance.
CMS Proposes Major Updates to Health Care Price Transparency Rules
On December 19th, The Centers for Medicare & Medicaid Services (CMS), in collaboration with other agencies, announced proposed updates to the healthcare price Transparency in Coverage (TiC) rules introduced during…
Payment Integrity Lessons from 2025 and What Payers Need for 2026
Explore how a unified platform can transform payment integrity in healthcare and tackle rising costs and claim complexities.
Frequently Asked Questions About Out-of-Network Claims and Pricing
Payers should look for an out-of-network claim pricing vendor that combines market-based pricing, configurable reimbursement logic, provider negotiation support and compliance-ready workflows. The right partner should help reduce claim costs while supporting transparency, defensibility and provider relationships. Strong out-of-network solutions also use data, benchmarks and routing intelligence to determine the best path for each claim, whether through pricing, negotiation, network replacement or other savings channels.
Payers can reduce out-of-network costs by using Zelis commercial and proprietary pricing methodologies and negotiation strategies that balance savings with provider acceptance. Out-of-network solutions should help determine when to apply reference-based pricing, pursue provider negotiation, use a network option or route the claim through another cost containment strategy. This helps payers lower avoidable spend, reduce disputes and create a more consistent experience for providers and members
Dynamic routing helps payers evaluate each out-of-network claim across available savings channels to identify the best path based on cost, compliance, provider impact and client-specific rules. Instead of relying on a one-size-fits-all workflow, dynamic routing can direct claims to multiple savings channels including negotiation, contract agreements, or reference-based pricing.. This helps payers improve savings, reduce unnecessary friction and maintain greater control over out-of-network claim outcomes.
Out-of-network solutions can help payers manage No Surprises Act and independent dispute resolution workflows by supporting defensible pricing, clear documentation and negotiation readiness. A strong vendor should help evaluate claim risk, benchmark reimbursement, support provider negotiation and strengthen IDR preparation. This gives payers a more consistent way to manage NSA-eligible claims, reduce administrative burden and improve confidence in pricing and dispute resolution decisions.
