Data Sheet: Integrated Secondary Editing Solution Now Available to HealthRules® Payer Clients

Integrated Secondary Editing Solution Now Available to HealthRules® Payer Clients

HealthEdge has unveiled an advanced secondary editing solution integrated within HealthRules® Payer, aiming to enhance claims accuracy, reduce overpayments, and streamline workflows for health plans. This innovative integration positions HealthEdge Source™ (Source) as a real-time secondary editor, operating between the primary editor and final claims adjudication.

What is HealthEdge Source?

HealthEdge Source is an interoperable, cloud-based platform designed to provide a comprehensive payment integrity solution. Its rich pricing and editing content libraries allow payers to address root-cause issues with full transparency and control over their operations. By automating data flow between HealthRules Payer and HealthEdge Source, the solution eliminates the need to switch the primary editing systems to achieve higher payment accuracy.

Key Benefits of Source as a Secondary Editing Solution

• Improved Claims Accuracy: Health plans can enhance the quality of claims by applying industry-standard billing rules and payer-specific policies.
• Reduced Overpayments: Integrate up-to-date editing information into the workflow to minimize costly errors.
• Fraud Detection: Enhance the ability to detect and mitigate fraud, waste, and abuse in medical services.
• Flexible Payment Options: Payers can pay, pend, or deny claims based on edit rules set in the Source.
• Simplified Maintenance: Reduce expenses associated with keeping edit rules current within claims adjudication systems.
• Enhanced Provider Relations: Increasing transparency through detailed audit trails improves relationships with providers.
• Business Intelligence: Optional analytics leverage centralized data for increased operational insights.

How It Works

When a claim is submitted in HealthRules Payer, it undergoes primary editing followed by secondary editing through Source via a real-time web service call. Source processes the claim and returns edit recommendations, which are then applied and visible in the HealthRules Payer system. Users have the flexibility to accept or bypass these recommendations and commit them to the Source History Database for future reference.

Conclusion

The integration of HealthEdge’s secondary editing solution within HealthRules Payer represents a significant advancement in payment integrity and operational efficiency for health plans. By using this solution, organizations can gain confidence in their payments and business decisions while improving overall claims management.

To learn more about leveraging this integrated secondary editing solution, contact us today or visit HealthEdge.