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:

• Negotiations are based on allowable charges
• No transaction fees are assigned to payer
• Only eligible claims are sent for negotiations
• Potential added savings may be captured on non-contracted claims
• Reporting capabilities capture re-pricing and out-of-network discount activity