Data Sheet: Take Control of Claims Editing with Advanced Custom Edits from HealthEdge Source™

Managing large and diverse member populations with unique healthcare needs presents significant challenges for health plans. Traditional editing solutions often prioritize identifying errors after the claims have been paid. This approach encourages finding errors after the fact rather than proactively addressing inaccurate payments from the start.

To address this, HealthEdge Source™ (Source) introduces Advanced Custom Edits, designed to enhance efficiency and accuracy in claims processing by utilizing historical data to create custom edits - all from within the familiar Source user-interface. By taking control of their own editing processes, health plans can make necessary adjustments in-house, instead of outsourcing to expensive recovery vendors.

Key Benefits of Advanced Custom Edits

1. Highly Customized Edits: Tailor edits to your organization’s specific needs and business rules.
2. Utilization of Historical Data: Refine claim processing and uncover trends by leveraging historical claim data.
3. Prevention of Overpayments: Eliminate costly post-pay recovery by preventing overpayments upfront.
4. Control Over Intellectual Property: Maintain full control over the execution, maintenance, and accuracy of intellectual property.

How Advanced Custom Edits Work

1. Create the Advanced Custom Edit

Authorized users can create custom edits directly within the user interface without needing IT involvement. The intuitive point-and-click functionality allows for building complex edit logic without coding expertise.

2. Add Current Claim Conditions

Define criteria that must be met on the current claim to trigger the edit, such as including claims with a specific service code.

3. Add History Claim Conditions

Set conditions based on historical member claim data to refine the edit’s scope, for instance, claims with a specific service code processed within the last 30 days.

4. Add Relational Criteria

Optionally, set up comparisons between current and historical data to identify claims that match the defined edit parameters.

5. Activate the Edit

Once all conditions are set, activate the edit within the system.

6. Process the Claim

Process claims through the newly created custom edits to ensure accuracy and efficiency.

Functionalities

Advanced Custom Edits go beyond pre-defined edits by analyzing the member's claim history, allowing health plans to identify potential irregularities with high accuracy. Users can easily tailor editing rules to address specific scenarios and unique business needs. The integration with existing Source instances and workflows ensures users don’t need to spend time learning new capabilities.

Achieving Unmatched Accuracy and Efficiency

HealthEdge Source’s Advanced Custom Edits empower health plans to significantly reduce errors, streamline workflows, and optimize operations. By taking advantage of member-specific claims history, health plans can achieve a new level of accuracy and efficiency in claim processing.

Current Source customers interested in leveraging these new capabilities should contact their Customer Success Executive to license this feature.