Prospective Payment Integrity for Enterprise Transformation

HealthEdge Source™ offers payers true Payment Accountability® with the ability to unlock transformation at the reimbursement, payment integrity, and enterprise level. Our Reimbursement Transformation features Medicare and Medicaid content coupled with flexible contract configuration capabilities for Commercial and Government lines of business. Payment Integrity Transformation includes rich editing libraries with history-based capabilities, easy development of customized edits, and improved transparency to reduce vendor dependency and increase control. As a complete solution, clients can achieve Enterprise Transformation, where root-cause issues are identified and addressed upstream, and all aspects of claims operations are centralized for comprehensive business intelligence.

Ppi systems overview

The Source Solution Suite

“By investing in a prospective payment integrity solution that highlights inaccuracies before the payment is made, you can stop the costly retroactive repayment process that negatively impacts your providers and members through administrative costs”

– Gartner®, Inc. U.S. Healthcare Payer CIOs Must Invest in Prospective Payment Integrity to Improve Member Experience, Austynn Eubank and Mandi Bishop, 24 March 2023. GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.

HealthEdge Source Medicare Reimbursement

Delivers, manages and maintains CMS pricing data for comprehensive payment accuracy.

HealthEdge Source Medicaid Reimbursement

Pay Medicaid claims accurately, quickly and comprehensively – the first time.

HealthEdge Source Commercial Reimbursement

A dynamic solution that simplifies contract configuration and provides accurate modeling.

HealthEdge Source Editing

Comprehensive support to handle complex policies automatically across all lines of business.

HealthEdge Source Platform Access

Enabling payers to gain control of their IT ecosystem through radical transparency.


Additional Offerings

HealthEdge Source Analytics

Our Business Intelligence capabilities enable enterprise-wide decision support for setting medical policy, renegotiating provider contracts, and identifying and remediating billing and utilization trends within your provider network.

HealthEdge Source Professional Services

Our Source experts are stewards of our solution, with a mission to equip your internal teams with the knowledge and support required to optimize your business.

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HealthEdge Source Third-Party Integrations

Incorporate third-party solutions and their data into a cohesive workflow for true interoperability of normally disjointed solutions. 

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What is payment integrity?

In healthcare, payment integrity refers to the efforts used to address the impact of inaccurate payments and fraud on members, payers and providers alike.

What does prospective payment integrity mean?

Prospective payment integrity refers to the ability for payers to proactively avoid paying claims improperly versus the traditional approach to paying and then addressing claims payment errors. Prospective payment integrity technologies enable accurate claims processing and minimize waste in the healthcare system.

What is Retroactive Change Manager?

CMS regularly enforces retroactive changes to fee schedules, edits, and pricer logic. In 2023, over 600 changes are expected to occur. The traditional approach to retroactive claims recovery forces healthcare payers to rely on internal teams and third-party payment integrity vendors to identify and recover over-and-under payments to providers--typically months after the changes occur, which drives up costs for administrative processing, produces waste, and strains payer-provider relations. Source Retroactive Change Manager automatically and proactively monitors for retroactive changes. This enables payers to accurately reprice and adjust over-and-underpayments with full transparency into the changes, generate variance reports to identify claims that require adjustments, and reconcile inaccurate claims immediately to improve compliance.

How is HealthEdge Source different from other payment integrity vendors?

HealthEdge Source is uniquely designed to empower healthcare payers through technology. Source enables payers to:

- See root-cause issues and readily address and correct them upstream in the adjudication process
- Automatically and seamlessly receive updates via cloud-based delivery of content and infrastructure
- Create custom edits and see results within minutes
- Model edits and fee schedule changes in real-time to accruately assess impacts down to the penny
- Scale and solve for long-term payment integrity goals

How does payment integrity impact healthcare providers?

The traditional approach to payment integrity contributes to increased clerical work and reduced performance for both payers and providers--leading to clinician burnout. Modernized payment integrity programs and a prospective payment integrity approach can reduce improper payments, thus cut back on rework, save time, streamline workflows, and improve communication between payers and providers.

What does it mean to create a "Virtuous Cycle" in payment integrity?

Unlike the traditional, segmented approach to payment integrity that only solves for improper payments after they have been paid with no insight into root-cause issues, creating a Virtuous Cycle in payment integrity incorporates reimbursement modeling, management and execution along with edit creation and data-driven business intelligence to address root-cause issues. This virtuous cycle unlocks enterprise transformation where healthcare payers have increased visbility and control over their own data.

Does HealthEdge Source integrate with other Core Administration Platform Solutions (CAPS)?

In addition to our Care-Payer integration, HealthEdge Source can integrate with any CAPS solution via a single API.


“When it comes to building and managing claims, I never want to go back to anything else.”

Director of Policy & Editing, Large Southeast Payer

"All of our pricing and editing is a one stop shop"

Melissa Rusk, Vice President of Operations, SummaCare
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