Emdeon Clinical Integrity for Claims

Emdeon Clinical Integrity for Claims offers payers flexible, transparent claims edits that leverage more than 16 million rules based on protocols from the American Medical Association, Centers for Medicare and Medicaid Services and other industry sources. Plus, Emdeon now makes it possible to apply edits prior to adjudication. As a result, the number of pended and rejected claims can be reduced resulting in a smoother, more consistent adjudication and fewer delays in provider reimbursement. This Software as a Service (SaaS) model delivers savings over and above existing legacy coding solutions that may require significant IT resources or infrastructure.

Traditional proprietary clinical edit solutions can lend themselves to an adversarial relationship with providers. With Clinical Integrity for Claims, edits are transparent and providers receive a consistent message when an error is found. By supporting all editing decisions with tools designed to help providers understand the industry guidance on which rules are based (e.g., the definition of a CPT Code), Clinical Integrity for Claims helps remove the basis of the adversarial paradigm and replaces it with an open and collaborative approach to clinical coding. Comprehensive web tools are offered through a single sign-on portal so payer and provider staffs can view industry edit rationale conveniently.

Another way to reduce lost revenue, increase profitability and enhance efficiency is to improve where payers look for billing and coding errors. With Clinical Integrity for Claims, payers can spot common problems like overpayment in real-time. The pre-adjudication model can remove much of the work needed by the adjudication system and claims adjusters, and can decrease downstream re-submits and appeals. Payers benefit from industry-leading overpayment protection supported by advanced algorithms, duplicate recognition logic and history-based edits.

Features

• Industry-leading clinical integrity services through the most advanced algorithms and duplicate claim checking logic in the market
• Proactive approach integrated in pre-adjudication claim delivery process
• Flexible configuration allows for complete codification of payer reimbursement policies for clinical coding
• Comprehensive web tools offer transparency for payer staff and providers to view industry edit rationale

Benefits

• Achieve immediate savings in time and money with minimal implementation effort
• Improve provider relations
• Enhance cost containment through improved claim accuracy and appropriate code correction
• Eliminate clinical integrity infrastructure maintenance
• Reduce number of pended and rejected claims through pre-adjudication, pre-delivery processing, resulting in a smoother and more consistent adjudication cycle