Claims Pre-Adjudication

An end-to-end Claims intake solution designed for real-time claims imaging and EDI data tracking from the time that documentation is scanned or uploaded. With increased effectiveness around HIPAA 5010 step-up/step-down, and ICD-10 edits, organizations can now aim for higher member and provider service levels.


Softheon Business Connector Cloud (BC2) Claims Pre-Adjudication gives healthcare payers all necessary tools when dealing with the Claims Pre Adjudication process. Softheon's BC2 solution integrates easily with a variety of Core Admin systems, including Trizetto FACETS, QMACS, Amisys, QCARE, Diamond, Peradigm, and Xcelys.

Additional benefits of the Softheon Claims Pre-Adjudication solution include:

  • Greater accountability by implementing the ability to audit and track claims cases and related documents
  • Achieve higher levels of accuracy around HIPAA 5100 and ICD-10 edits
  • Link claims and claim-related information with a subscriber and/or provider to offer a more complete picture
  • Create folders that store claim-related information by manually scanning or uploading documentation
  • Free up space required to store paper-based claims, thus eliminating the need for off-site external storage facilities
  • Seamless integration with legacy technologies, such as portal applications
  • Allow access to member or provider claim information and claim history
  • Implement and verify business workflow processes by using Softheon electronic folders which are comprised of claim metadata values and related gathered documentation
  • Allow for interdepartmental communication and the transfer of cases in real time
  • Provide the ability to institute off-shore or remote processing from any readily avaliable internet connection
  • Allow for replacement or reference of existing content repositories
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