Claims Editing System Application Managed Services

This case study details the implementation of the Claims Edit System (CES) by Optum, which aims to assist health plans in managing claim editing challenges. The document outlines the complexities faced by health plans, such as maintaining regulatory compliance and managing clinical content. It describes how CES automates the editing of claims for clinical coding and billing errors based on industry rules and regulations. The case study highlights a national health plan's experience, which achieved significant savings and efficiency through the application of CES and Application Managed Services (AMS). The AMS team provides ongoing support, ensuring the CES remains effective by managing software operations, driving savings, and implementing best practices. The document also discusses the importance of continuous updates to the CES knowledge base to reflect regulatory changes and the role of a physician-led ideation team in identifying cost-saving opportunities. Overall, it presents a comprehensive approach to optimizing claims editing processes.