Start your payer engines

Trusted core administration and claims management engines

For the past 20 years, PLEXIS has honed our understanding of payer’s needs with our core administration & claims management solutions, and we’ve gone the extra mile with extensible business apps, our powerful Passport connectivity services, and a host of best-in-class professional services.

PLEXIS Payer Platforms

PLEXIS platforms are first and foremost trusted, time-tested core administration (benefit administration) and claims management engines. We empower domestic and international payer success through the solid technological foundation of our SQL-based platforms.

Easy to configure, agile enough to address demanding business needs, and flexible enough to capitalize on new growth opportunities, PLEXIS payer platforms deliver:

  • Claims management, including claim auto-adjudication
  • Benefit administration
  • Robust member and eligibility management
  • Premium billing administration
  • Real-time claim editing
  • Mass claim re-adjudication
  • Intelligent alerts and reporting
  • Provider administration/referrals and authorizations
  • Capitation capabilities
  • Easy-to-manage multi-level security
  • Configurable add-ons such as external Medicare grouper and pricer routines
  • Reference data loaders that automatically load procedure/diagnosis codes, UB04, NCCI data, etc.

See additional benefits of the most trusted core administration and claims management engines on the market:

  • Process claims on a familiar Windows interface with hot keys.
  • Save time managing membership and eligibility, including individuals who are dually eligible for Medicare and Medicaid.
  • Meet cost containment objectives by investing in affordable core administrative processing technology for the greatest ROI.
  • Automate complex benefit calculations and drive high auto-adjudication rates with PLEXIS’ rules-based engine.
  • Simplify regulatory compliance with HIPAA-ready EDI (Electronic Data Interchange), supporting ICD-10, CMS 1500, and UB04.
  • Conduct Encounter Reporting in compliance with CMS and state Medicaid protocols.
  • Automation of claim late payment penalty and interest calculation.
  • Stay in control of the information that various users are authorized to view with PLEXIS’ smart portal solution, WEBWorks™
  • A full library of standard reports available for use and custom modification.
  • Send automated, intelligent alerts to a variety of user-defined media devices including a cell phone or pager using Business Activity Monitoring (BAM) via PLEXIS Alerts™
  • Customize result/EOB codes and control their action (deny/pend/approve).
  • Proactively implement changes before they take effect using effective from and through dates.
  • Generate and manage AP and AR transactions automatically or manually.
  • Drive outcomes with an agile, dependable software solution based on flexible configuration capabilities.
  • Invest in technology with the assurance of proven reusability to ensure success throughout ongoing changes in healthcare policy and technology.