Claims Editing

Fast, precise edits deliver savings and compliance with changing regulations.

Identify errors pre-payment with Claims Editing.

The best approach to identifying billing errors is to spot them prior to payment. We examine every claim using a combination of millions of edits, historical data, industry knowledge, and the expertise of a team of certified professional coders, registered nurses, and medical doctors.

Edits are customized to align with each plan’s in-house medical, benefit and payment policies, and consistently reviewed and updated to identify future edits and ensure compliance with CMS and other nationally recognized sources.

This is not another added layer of administrative burden: it’s fully integrated into your core claims processing system, delivering the perfect balance between accuracy, savings and provider and member satisfaction.

Today, over 160 payers trust Zelis to deliver targeted and efficient edits post-adjudication and pre-payment. Our claims processing platform delivers complete flexibility and customization, alongside maximum savings, all post-adjudication and pre-payment.

Post-Adjudication, Pre-Payment

Streamline implementation and keep claims processes intact through integration with all major adjudication platforms. Ensure accuracy – before payment – with over 18 million customizable and continuously updated edits to find savings and reduce the costs incurred with pay-and-chase scenarios.

National Coding Standards

Ensure reliability and defensibility of all edits.

Customizable Edits

Target specific claim scenarios to ensure accurate application of edits per payment policies and trends.

Clinical Oversight

Review claims proactively, with insight from CPCs, RNs and MDs.

For Payers

Zelis Claims Editing enables you to:

Integrate claim edits into pre-payment processes
Find new claims savings opportunities proactively
Reduce claim appeals with adherence to coding standards
Customize claim editing process to meet in-house guidelines

Zelis by the Numbers

Measurable savings on every claim:

80 %

of claims contain coding or other errors

< 5 %

of Zelis claims edits are disputed

< 2 %

of Zelis claim edits are reversed

Testimonials

Claims Editing in action.

“Our total savings in just the past year topped $4.1 million resulting in $24.98 PEPM savings. A huge benefit is the ability to customize edits for specific services. Being able to turn edits off and on by client or even apply them down to the provider level has assisted us immensely.”

– Mary, COO of TPA

“Working with Zelis has helped us take an end-to-end approach to problems starting with pre-payment, looking at the best way to pay those claims initially to get the best pricing available. We work with Zelis from pre-payment through sending the payment.”

– Steve, COO of TPA

“They have excelled at finding large dollar overpayments that have enabled us to exceed our goals.”

– Angela Manager at National Health Plan

Take the Next Step

Learn how Zelis Claims Editing uncovers savings every day.

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