ClaimsBridge Navigator’s Out of Network Services provides a comprehensive suite of tools for managing out of network costs.

Our ClaimsBridge Celerity claims engine allows customers to configure cost containment solutions at a client, geographic and line of business level. Combining Medicare level pricing, claim negotiation, contracting, balance bill and legal defense maximizes savings and minimizes disruption for members.

Pricing Transparency tools that conform to NSA and CAA guidelines as it relates to IDR/Arbitration, Qualifying Payment Amounts and Machine Readable files are included in our offering.

  • Medicare Pricing
  • Claim Negotiation
  • Transparency Tools (IDR/QPA/MRF)
  • SPD Support & Guidance
  • Balance Bill/Appeals Management
  • Legal Defense Services

Qualifying Payment Amount (QPA) Integration. In response to the No Surprises Act (NSA), ClaimsBridge has teamed up with a business leader in Healthcare data analytics, to automatically update any out on network claim with a QPA value. This enables payers and employers to respond on a timelier basis to any Independent Dispute Resolution (IDR) case.

The claim can be referenced for it’s QPA value from the client claim system or the ClaimsBridge user portal as it is automatically added as the claim flows through the ClaimsBridge Celerity Engine.

QPA values are derived according to CMS specifications from their database of 77Billion claims records.

When requested supporting data can be provided during IDR process to validate the QPA valuation.

Machine Readable Files (MRF).  As part of the Pricing Transparency Act (PTA) group health plans are required to disclose publicly their network rates in an MRF. For all networks that ClaimsBridge build within the ClaimsBridge Celerity Engine, ClaimsBridge has developed an automated output and a web platform for publishing MRFs.

Additionally, the Allowed amount file which is also required as part of the NSA is also automatically created and published based on the historical data of claims processed by ClaimsBridge Celerity.

Independent Dispute Resolution (IDR) Process and Services. The IDR Process set forth in the No Surprises Act went into full effect on January 1, 2022.

ClaimsBridge is prepared to provide health plans with comprehensive services to comply with every aspect of the IDR Process from commencement of the Open Negotiation Period to final resolution.

ClaimsBridge executes this service through our client services team and our legal business partner.

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