Healthcare and Life Sciences: Claims Management
Payer and health plan claims adjudication covers intake of medical claims, eligibility and benefit verification, pricing, clinical and coding review, and payment or denial. Examiners spend much of their time moving between the core claims platform, provider and member portals, policy and fee schedule documents, and email or chat to resolve pends. Exceptions such as missing authorizations, coordination of benefits questions and suspect coding drive most of the manual effort.
Claims Management in Healthcare
Payer and health plan claims adjudication covers intake of medical claims, eligibility and benefit verification, pricing, clinical and coding review, and payment or denial. Examiners spend much of their time moving between the core claims platform, provider and member portals, policy and fee schedule documents, and email or chat to resolve pends. Exceptions such as missing authorizations, coordination of benefits questions and suspect coding drive most of the manual effort.
Example product views. Figures shown are illustrative.
What Pyze Measures
- Elapsed and hands-on time per adjudication stage
- Application and screen sequence for pended claims
- Rework loops between examiners, clinical reviewers and provider services
- Variation in handling paths for the same claim type across teams
Typical Findings
- Pended claims that require an authorization check typically involve a switch to an external portal and back to the claims platform before adjudication resumes.
- Coordination of benefits cases follow several different lookup paths depending on the examiner, with repeated reference to documents outside the core system.
- Escalations to clinical reviewers travel through email and chat, which adds waiting time between the pend and the decision.
What the Opportunity Register Supports
- Supports a ranked register of adjudication steps suited to integration with authorization and eligibility sources.
- Quantifies the effort in pend resolution paths where an AI agent could prepare the supporting evidence for the examiner.
- Supports standardizing handling paths for claim types that currently vary by team.
Example Opportunities
- 1.Manual Authorization Lookups on Pended Inpatient Claims Integration Automate
- 2.Coordination of Benefits Research Across Portals AI Agent Agentify
- 3.Fee Schedule Reference in Spreadsheets for Pricing Exceptions Standardization Standardize
- 4.High-Latency Handoffs Between Examiners and Clinical Reviewers UX Simplify
- 5.Uneven Pend Queue Distribution Across Examiner Teams RPA Rebalance
Roles and Titles
- Chief Operating Officer
- Head of Claims
Chief Claims Officer, SVP Claims, VP Claims Operations
Claims Management in Other Industries
Other Healthcare and Life Sciences Functions
See This on Your Own Work
A measured baseline before anything changes, then a priced and owned list of what to do about the gaps.