Claims Editing Software

Vendor to deliver a comprehensive post‑adjudication, pre‑payment claims editing solution that enhances claims accuracy, strengthens compliance, and prevents improper payments.
- The solution must also support the configuration and development of custom edits as needed, while ensuring successful implementation, ongoing maintenance, and continuous optimization of the claims editing platform and all associated components.
- The service will include standard rule‑based edits, complex logic editing, historical claims review, and specialty‑focused editing in high‑risk areas (including, but not limited to, hospice and laboratory services). The vendor must provide robust capabilities to configure and create custom edits, simulate complex methodologies, and perform targeted analytics to identify emerging billing risks, missed savings opportunities, and complex coding inaccuracies prior to payment.