Skip to main content

         This documentation site is for previous versions. Visit our new documentation site for current releases.      

Healthcare ClaimsXten

Updated on October 9, 2020

ClaimsXten™ is the code-auditing tool developed by Healthcare Information Solutions, Inc. It has extended auditing software capabilities with expanded claim processing capabilities, including automated claim review and code auditing, which helps payers implement and manage their full spectrum of claims payment policies. ClaimsXten offers flexible, rules-based claims management with the capability of creating customized rules, as well as the ability to read historical claims data. ClaimsXten uses specific criteria to foster decisions that ensure that payment policies are aligned with product design, provider contracting, and medical policies. This assists in adjudicating claims in a manner that is more efficient and cost effective.

The Pega ClaimsXten Adaptor provides for the integration of ClaimsXten, a full-service claim editing and auditing solution with Pega claim processing functionality. Increasingly complex plans, plus more and varied lines of business, can push healthcare payers' claims payment systems beyond their ability to deliver the necessary speed and accuracy. ClaimsXten is a durable, flexible solution for clinically-based claims auditing that offers flexible rules creation and firing that enable payers to process each claim under the specific terms and conditions of each benefit plan.

Healthcare ClaimsXten combines the strength and flexibility of the Healthcare Total Payment™ platform, a comprehensive library of Healthcare clinical rule content, and a services team of medical claims experts to provide payers with more medical and administrative savings opportunities. With full-service, technologically advanced ClaimsXten, you can do much more than standard fee-for-service claim code editing.

With ClaimXten, you can:

  • Increase auto-adjudication rates
  • Adjudicate ICD-10 claims with rules that look at historical claims coded in ICD-9
  • Consistently and accurately apply policies - across plans, regions and claims processing systems
  • Pay claims more accurately while reducing administrative costs
  • Shift processing burdens to extend the useful life of your claims processing system(s)

The ClaimsXten solution contains KnowledgePacks consisting of individual claims management rules. Each of these rules is associated with specific edits. KnowledgePacks are currently available for auditing professional (provider) and outpatient facility claims. This includes but is not limited to:

  • CPT-to-CPT procedures, Diagnosis-to-procedure options
  • Medicare and Medicaid-related auditing logic found in the Correct Coding Initiative (CCI)
  • Other centers for Medicare and Medicaid Services (CMS) carrier directives (for example, National Coverage Determinations for medical devices and other complex procedures)
  • Outpatient Code Editor (OCE) rules

A ClaimsXten rule is the logic necessary to execute a specific payment policy or guideline. Each rule has an associated set of clinical data contained in Dictionary Category tables that, when applied to the rule logic, results in an edit. The edit is a recommendation made by ClaimsXten to deny, review, modify, or allow a specific claim line.

Have a question? Get answers now.

Visit the Support Center to ask questions, engage in discussions, share ideas, and help others.

Did you find this content helpful?

Want to help us improve this content?

We'd prefer it if you saw us at our best. is not optimized for Internet Explorer. For the optimal experience, please use:

Close Deprecation Notice
Contact us