Skip to main content
logo Contact us

Video: Third Party Ecosystem in Source - HealthEdge Source

The HealthEdge Source Third-Party Ecosystem empowers health plans to streamline their payment integrity operations through seamless integrations with industry-leading vendors. By configuring pricers and edits directly within the Source application, organizations can significantly reduce administrative burden, consolidate vendors, and drive substantial cost savings without the need to manage individual vendor relationships.

HealthEdge Source manages the updates, maintenance, and relationships on behalf of the health plan, delivering a unified solution that enhances automation and regulatory compliance.

Key Operational Benefits

Leveraging the Source Third-Party Ecosystem as a primary or secondary editor allows health plans to optimize their payment integrity stack and realize immediate value:

  • Proven Cost Efficiency: Clients have reported measurable savings when enabling third-party libraries within Source, including:
  • 2% savings on a $6 PMPM drug spend with RJ Health.
  • 10% savings on a $1.30 PMPM genetic testing spend with Concert Genetics.
  • 0.5% savings on Medicare Advantage/Dual spend with MediQuant.
  • Reduced Administrative Lift: Third-party updates are automatically delivered, ensuring instant access to the latest regulatory data.
  • Streamlined Auditing: The audit trail provides full transparency, returning all applicable edits and includes live links to policy documents.

Integrated Solutions and Capabilities

The ecosystem supports five critical third-party integrations, each offering robust configuration options such as monitoring mode, disposition adjustments, and custom exceptions:

  1. RJ Health (High-Cost Drug Pricing):
  • Ensures accurate reimbursement for HCPCS/NDC-coded drugs.
  • Manages dosing, invalid codes, and flexible pricing (AWP, WAC, ASP).

2. MediQuant (Medicare NCDs & LCDs):

  • Automates medical necessity edits and simplifies claims for Medicare Advantage.
  • Reduces rework with logic for codes, dates, and add-on procedures.

3. Concert Genetics (Genetic Testing):

  • Clarifies coding for genetic testing, including molecular pathology and sequencing.
  • Flags issues like unbundled codes and missing diagnoses.

4. 3M (APR DRG & EAPG Pricing):

  • Provides Medicaid-specific pricing for inpatient and outpatient claims.
  • Enforces edits for MUEs, invalid procedures, and billing guidelines.

5. American Society of Anesthesiologists (ASA):

  • Integrates ASA anesthesia billing rules, including modifiers and crosswalking.

By centralizing these solutions, the HealthEdge Source Third-Party Ecosystem provides a sophisticated, automated approach to managing complex claim edits, allowing health plans to focus on strategic growth and member outcomes.