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The ClaimsExchange service is integrated with the QicLink™, Facets™ and QNXT™ enterprise core administration systems to seamlessly connect healthcare payer organizations to a vast network of PPOs for electronic claims routing and re-pricing via a single point of connectivity. This automated service has highly configurable routing rules to support complex workflows, real-time re-pricing in conjunction with Cognizant’s line of TriZetto network management solutions and the exchange of fraud and abuse data with trading partners.
Pre-Adjudication – ClaimsExchange is 5010 and ICD-10 compatible and reduces payer/PPO barriers. By integrating the multitude of PPOs directly into the process flow, claims can be accurately re-priced based on the provider databases and contract parameters in effect.
Post-Adjudication – ClaimsExchange automatically captures discounts on out-of-network claims via a post-adjudication interface with fee negotiators. Claim selection takes place after a claim has been adjudicated in the QicLink or Facets application. This allows the claim to be negotiated for a discount after benefit determination but prior to payment—reducing adjustments due to ineligible claims.
Benefits of this unique post-adjudication functionality:
Optimize operations and extend application functionality
Comprehensive functionality to support specialty lines of business
Effective tools that support today’s complex provider network and care management initiatives
Manage the cost and quality of care with access to affordable, QicLink-integrated solutions
Connect to a vast network of PPOs for electronic claims routing and re-pricing