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From Guessing Game to Proactive Process: Simplify Edits with HealthEdge Source™

Published Date
Author Christopher Walker

Healthcare payments are not as simple as they used to be. As medical treatments, billing models, and regulations have grown more complex, health plans now face a confusing mix of pricing rules, policies, and vendor relationships that make it challenging to manage payments accurately and efficiently. 

With the HealthEdge Source™ prospective payment integrity solution, health plans get access to editing, modeling, and payment capabilities within a single platform—helping ensure claims are processed correctly the first time. Now, we’re introducing two key improvements to our Edit Management feature that give payers more control and improved transparency. 

Simplifying Edit Configuration 

Managing claims edits used to mean navigating several separate screens and manually updating rules for each provider type, which is both tedious and error prone. Now, HealthEdge Source offers a single, consolidated interface where all configurations happen in one place.  

For example, if a plan wants to enable prior authorization for high-cost imaging, this can be enabled with a single click for every relevant facility or provider group. If there’s a need to make an exception, such as excluding emergency services from this rule, it takes only a few seconds to adjust, rather than repeating the change across multiple screens. 

This approach makes policy management far more efficient. Teams can view, enable, adjust, or turn off edits for different provider types using simple checkboxes in the same dashboard, rather than tracking changes separately. It’s much easier to implement organization-wide policies or fine-tune rules for special cases without losing sight of the bigger picture. Centralizing these functions not only saves time but also reduces the risk of mistakes and ensures all updates are reflected everywhere they should be. 

Global Edit Exceptions 

With global edit exceptions, users can create exception rules in one central location, then apply them across as many edits as needed. For example, if a particular provider, like a large hospital network, should be exempt from certain claim edits due to a unique contract, the team only has to set up their tax ID or configuration details once. This rule can then be linked to every relevant edit, instead of repeating the same exclusion logic each time. This centralized approach cuts down on repetitive work and makes it easier to standardize processes across the organization. 

When a contract changes or another provider needs a similar exception, users simply update the global exception in the central library, and the change automatically applies to every connected edit. This greatly reduces the risk of missing updates or having inconsistent rules across different parts of the system. For example, if a health plan wants to exclude urgent care claims from certain checks or adjust exclusion criteria for a set of specialty providers, those updates can be handled quickly and accurately by revising a single rule, rather than searching for and editing each instance individually. 

Ultimately, this approach delivers a stable, scalable foundation for controlling edits: faster updates, less risk of error, and transparency for compliance. Health plans keep pace with regulatory shifts or network changes, managing them as a controlled process rather than a scramble. 

A Practical Solution: The HealthEdge Source Approach 

HealthEdge Source recognized that the market didn't need another standalone editing or pricing tool—it needed a new way of thinking. The solution wasn't to add another layer to the already convoluted stack, but to build a new foundation from the ground up. 

The platform aims to solve these problems by giving health plans tools to catch mistakes before payments go out. Instead of stacking more vendors and manual checks, HealthEdge Source combines claims, configurations, edits, and analytics in one place for better control and visibility. 

How HealthEdge Source Simplifies Claims Management 

  • Easy Edit Building: HealthEdge Source includes a no-code edit builder, allowing users to create and update payment edits themselves. There's no need to wait for engineering teams or new software releases. An edit can be built and published in minutes. 
  • Automatic Updates: The platform keeps up with regulatory changes from organizations like the Centers for Medicare and Medicaid Services (CMS) automatically. Rules are updated every two weeks, so there’s no need for health plan teams to download or upload changes manually. 
  • Test Before Going Live: The Monitor Mode feature allows users to test new edits on real claims without affecting actual payments. This lets teams see the impact of a new rule before fully implementing it. 
  • Clear Tracking and Analytics: Every claim is tracked with a detailed audit trail, and the system offers advanced analytics to help health plans spot trends, track performance, and make better decisions. 

By uniting all of these components, the platform turns payment accuracy from a guessing game into a straightforward, proactive process.  

For an in-depth look at these enhancements in action, don’t miss the on-demand webinar: Edit Smarter Not Harder with HealthEdge Source. Get an inside look at how connected, automated payment integrity can work day to day.