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
Zelis Open Access Pricing®
Predictable pricing for you. Real provider choice for members. Controlled savings for everyone.
What Open Access Reference-Based Pricing Can Do for Your Plan
Optimize network configurations
Leverage any combination of provider contracts: payer owned, Zelis owned or Zelis partners.
Cut costs — without cutting access
Set limits on rising healthcare expenses while freeing members from traditional PPO restrictions.
Protect members at every step
Support members with a comprehensive advocacy program — so they don’t navigate disputes alone.
Guide members to better decisions
Empower members with a decision-support app that helps them compare provider price and quality data.
Give brokers clearer visibility
Search providers by location, RBP acceptance status and more to support informed decision-making.
Expand the provider network
Zelis Open Access Providers℠ direct agreements reduce member abrasion and better predict costs.
Make Open Access Work
What if there was a hassle-free way to control healthcare costs and empower members to find and pay for quality care?
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How Zelis Helped a Member Save $51K on Their Health Bill
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
Reference-based Pricing Resources
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.
Closing the Price Transparency Gap: How Payers and TPAs Can Deliver Real Value
Close the price transparency gap and deliver real value with smarter data, simpler design and stronger employer partnerships.
Frequently Asked Questions About Reference-based Pricing
Reference-based pricing, or RBP, helps TPAs and self-funded employer groups set SPD-defined reimbursement limits using established benchmarks instead of relying only on traditional PPO network discounts. Zelis Open Access Pricing helps TPAs control rising healthcare costs while giving members more freedom to choose providers. The solution combines claim pricing technology, configurable reimbursement logic, provider transparency, member advocacy and balance bill support to create a more predictable, member-centered alternative to traditional network models.
A TPA can use reference-based pricing as a full network replacement, a wrap around a narrow primary network, part of a tiered network strategy or a facility-focused pricing approach. Zelis Open Access Pricing gives TPAs flexible configuration options based on plan goals, provider access needs and employer group tolerance for disruption. This helps TPAs expand coverage, reduce dependency on traditional PPO networks and create more cost-effective plan designs for self-funded groups.
Open Access Pricing reduces balance billing and member disruption by surrounding reference-based pricing with member advocacy, provider education, pre-service outreach, balance bill resolution and legal escalation support. Members can get help finding providers, confirming plan acceptance and resolving bills that exceed plan liability. This support helps TPAs protect the member experience while giving employer groups a more affordable healthcare plan option that does not rely solely on traditional PPO contracts.
TPAs should look for a reference-based pricing vendor that offers more than claim repricing. A strong RBP partner should include benchmark pricing, contract management, performance reporting, provider transparency, member decision support, provider contracting support and balance bill resolution. Zelis Open Access Pricing brings these capabilities together with direct provider agreements, Compass Connect member decision support and legal escalation services to help TPAs improve savings, reduce abrasion and support long-term plan acceptance.
Yes. Reference-based pricing can be configured as a full network replacement, a wrap around a narrow primary network, part of a tiered network strategy or a facility-only solution. Zelis Open Access Pricing gives TPAs flexibility to align the model to each employer group’s savings goals, provider access needs and tolerance for disruption. This allows TPAs to introduce RBP where it creates the most value without forcing a one-size-fits-all network strategy.
Zelis helps TPAs reduce balance bill risk with member advocacy, pre-service outreach, provider education, balance bill resolution, provider contracting support and legal escalation services. Members can receive support before and after care, including help finding plan-accepting providers and resolving bills that exceed plan liability. This gives TPAs a more complete RBP operating model that protects savings while supporting member confidence, provider communication and long-term plan adoption.
