Payer Claims Expertise

Claims That Close Fast

Claims processing is the core of health plan operations — accuracy, speed, and compliance determine both member satisfaction and administrative cost. Hetasalvation's claims processing specialists support health plans, TPAs, and insurance companies with end-to-end claims management — from EDI intake to adjudication and payment.

We combine deep domain knowledge with automation and AI to improve auto-adjudication rates, reduce claim errors, and lower the cost to process each claim.

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Claims Services

End-to-End Claims Management

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EDI Claims Intake

Electronic claim receipt and validation — 837P/837I processing, acknowledgment generation, and real-time claim status reporting.

837P / 837I claim intake
999 / 277CA acknowledgments
EDI translation & validation
Claims clearing house management
Paper claim scanning & OCR

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Claims Adjudication

Accurate, automated claims adjudication against member eligibility, benefits, and contract terms — maximizing auto-pay rates and reducing manual touch.

Benefits configuration & adjudication
COB (Coordination of Benefits)
Auto-adjudication optimization
Fee schedule application
Payment calculation & issuance

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Claims Integrity & Fraud Detection

Pre- and post-payment claims integrity — identifying billing anomalies, duplicate claims, unbundling, upcoding, and fraudulent billing patterns.

Duplicate claim detection
Unbundling / upcoding detection
Predictive fraud analytics
NCCI edit application
SIU referral workflow

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Claims Re-adjudication

Systematic re-adjudication of claims affected by rate changes, benefit corrections, or system errors — ensuring payment accuracy across historical claim populations.

Mass re-adjudication campaigns
Rate change re-processing
Benefit correction re-adjudication
Retroactive eligibility adjustments
Recovery & overpayment management

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Claims Analytics & Reporting

Claims performance dashboards and analytics that track processing volumes, auto-adjudication rates, denial rates, and cost-per-claim trends.

Claims volume & throughput reporting
Auto-adjudication rate tracking
Denial analysis by denial code
Turn-around time monitoring
Provider payment trend analysis

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Provider Dispute Resolution

Efficient provider dispute and appeal management — tracking, investigation, resolution, and communication workflows that maintain positive provider relationships.

Provider dispute tracking system
Claim appeal investigation
Resolution workflow management
Provider communication management
Dispute trend analysis

Claims Processing