For Payers

Claims administration


Do more with less across your entire organization with insightful, end-to-end claims management

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Commercial plans

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Medicare and Medicaid

Health insurance repricing plans

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International (expat) plans

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Individual / family plans

Why settle for an outsourcer when you can engage a transformation partner?

Claims outsourcing is rife with metrics — accuracy, turnaround time, etc. Claims metrics alone, however, miss the mark in yielding meaningful benefits to your organization.


The truly meaningful benefits are hard to measure in siloed claims departments — such as brand perception improvements, new member referrals, satisfaction levels, etc.

Only a true partner with a view of the end-to-end claims process can deliver value-added benefits to claims and your organization as a whole.

HGS Healthcare, a leader in transformative healthcare solutions, can manage all or singular aspects of claims, help you avoid the downstream impacts of mishandled claims, and truly differentiate your organization.

Continuously improve claims and related processes with our 360-degree view

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Improve intake processes

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Increase speed and efficiency

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Reduce inaccuracies and rework

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Enhance provider and member satisfaction

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Reduce fraud, waste, and leakage

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Optimize claim payment and support

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Reduce grievances, complaints, and calls

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Protect the brand and improve perception

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Improve scalability and business continuity

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Increase transparency and trust

Automating claims is just the beginning

While most claims adjudication processes have been automated, what falls out of auto-adjudication are the highly complex claims. Resolving issues with these claims requires an understanding of plans, members, and providers; adjudication platform(s); as well as the contractual, medical policy, and coding outliers. With a deep understanding of both payer and provider operations, we partner with you to continuously improve and innovate.

Squeeze the most out of claims processing technologies

Exceed service level targets with optimized software — Facets, QNXT, Health Rules Payor, InsPro, Amisys, PowerHMS, Mainframes, and more.

With an in-house HGS Healthcare Technology team and an understanding of upstream and downstream impacts of system changes, our team can help you overcome IT obstacles with:

  • Workflow and software analysis
  • Customizations and configurations
  • Automation and auto-adjudication
  • Integration and interoperability
  • Reporting/analytics
  • Process mining technologies
intelligent robotic automation

Benefit from our 21+ years of claims experience

10 health plans in 50 states

72 Mclaims handled annually

$65 Bin payouts handled annually

14different claims platforms

+99.9metric efficiency for all health plans

3.5 yearsaverage tenure for claims agents

$100 Msavings for clients every year

4500 FTEsacross 3 different geographies

Avoid fragmented adjudication with our Claims Center of Excellence

With HGS Healthcare, up to 80% of claims can be processed automatically. Our claims team works to continuously improve automatic processes, while also preparing to handle the unusual claims – the exceptions.

Our claims specialists train for an average of six months. They are fully equipped to handle rework and the 20% of claims that require a complete review and application of benefits, pre-authorization decisions, and contractual carve-outs.

We take a “can do” approach to claims, as we aim to provide value, not just metrics. We proactively flag pre- and post-pay deficiencies so they may be investigated to avoid further issues.

Our Claims Center of Excellence (CCOE) harvests the very best ideas to promote collaboration and continuous improvement.

The CCOE is involved in:

  • Establishing new programs
  • Auditing and measuring efficiency
  • Investigating new tools and techniques
  • Identifying end-to-end opportunities for process enhancements or differentiation
  • Ensuring a consistent and “zero-surprise” service delivery
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Medical claims

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Dental claims

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Vision care claims

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Pharmacy claims

Ready to engage an insightful claims transformation partner?

Book a free consultation

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