Latest innovation offers distinct advantages that fuel health plans with greater efficiency, accuracy, and transparency to manage costs, optimize networks, and mitigate financial risk.

Boston, M.A. — March 26, 2024 – Zelis, a leading provider of healthcare technology solutions, announced today its newest service offering: In-Network Pricing and Contract Modeling. The addition of this solution further solidifies the company’s position to help health plans understand and proactively navigate claim pricing, processing and financial impacts resulting from contract changes. Rounding out the company’s full-service claim-pricing suite, health plans can now benefit from a comprehensive solution set that enhances precision and transparency in contract claim pricing and comparative modeling.

This all-in-one, highly configurable solution offers a clear expectation of cost, allowing health plans to more accurately price contracted claims. The solution allows for full access to Zelis’ library of pricing methodologies so that in less than a second, health plans can automatically price against any contracted rate, including commercial, Medicaid, Medicare, Tricare, and other programs. Access to this library and Zelis’ technology, in addition to support from experts who can reduce the burden of administrative tasks like uploading contracts and fee schedules, work in concert to expedite the overall claim pricing process.

Unlike other similar solutions, Zelis’ In-Network Pricing and Contract Modeling solution reduces friction between health plans and healthcare providers and helps providers avoid balance billing members. Now they can view line-by-line pricing formulas for each repriced claim to understand exactly how the claim was repriced and if any edits were applied. The payer can share this process trail with the contract terms with their providers to show the flow of the claim to confirm accurate pricing. This unique capability supports greater transparency and improved experience for all parties. The launch of In-Network Pricing and Contract Modeling follows Zelis’ recent partnership announcement with Availity, the nation’s largest real-time health information network. This partnership streamlines the end-to-end process between healthcare payers and providers, as another down payment on modernizing the healthcare financial experience for all.

“We understand that navigating complex stakeholder relationships and evolving healthcare regulations requires more from a cost management partner than strictly managing cost,” said Jay Deady, President of Price Optimization for Zelis. “Platform solutions like this compound efficiencies, enhance the member experience, minimize payer-provider abrasion, and lower the overall cost of care for everyone involved.”

Zelis’ full-service pricing suite also includes the following:

Out-of-Network pricing and services: A dynamic optimization engine with customizable rules to automatically route claims that fall out of network to the best savings channel. The services within the out-of-network solution suite include:

  • Expert claim negotiation through provider relationships, coding expertise, and historical benchmarks.
  • Market-based pricing strategies that improve transparency, reduces provider abrasion, and drive savings.
  • Adequate coverage of specialty networks.
  • The insights and tools to ensure compliance with federal guidelines and regulations related to surprise bills.

Open Access Pricing: Zelis Open Access Pricing® is a member-centric reference-based pricing plan that sets maximum reimbursement amounts using pre-defined prices, providing a controlled savings model that gives members more control over their healthcare provider choices and healthcare spend.

“Health plan contracts aren’t designed in a one-size-fits all manner and this new, highly customizable solution completes our suite of offerings to ensure we have the ability to service our clients’ unique needs in a high-touch, collaborative approach,” said Deady. “We load and maintain client contracts and fee schedules, manage the contract inventory, and price claims against them for all plan types. When paired with our other pricing services, these offerings can dramatically reduce administrative load and increase pricing transparency and accuracy.”

Learn more about the Zelis In-Network Pricing and Contract Modeling solution.

About Zelis

Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. This platform serves more than 750 payers, including the top 5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients. Learn more at Zelis.com and follow us on LinkedIn to get the latest news.

Media Contacts

Red Thread PR on Behalf of Zelis
[email protected]