Claim Repricing Services for Faster Turnaround and Lower Costs
PCH Health offers advanced claim repricing services designed specifically for TPAs, health plans, and cost containment companies seeking cost-effective, accurate, and timely claim management. Our claim repricing solution is engineered to streamline the entire claims repricing process by seamlessly integrating with both regional and national PPO networks through a single, centralized interface.
With over 30 years of expertise, we deliver healthcare repricing solutions that not only reduce administrative burdens but also generate substantial cost savings. Our robust PPO routing for healthcare ensures optimal routing of claims to the most appropriate network, enabling faster turnaround, increased efficiency, and improved accuracy.
Our proprietary optimization engine includes a smart edit layer that incorporates HIPAA compliance, current clinical guidelines, coordination of benefits (COB), and customizable client rules. This results in enhanced payment accuracy and fewer downstream denials or appeals, all vital to payer satisfaction and cost containment.
Our End-to-End Claims Repricing Process Includes:
Claim aggregation
We collect claims from multiple intake channels, including PO Box, secure web portals, DDE, fax, email, mobile apps, EDI, scanning, and physical mailrooms, ensuring a comprehensive and flexible claims intake process.
Extraction and routing
Using automated tools, we sort, batch, extract key data fields, and enable intelligent ppo routing for healthcare, guiding claims to the correct network path for accurate repricing.
Enrichment
Our rules engine validates and enriches incoming data, applies pre-edits, and ensures claims are fully prepared for accurate processing. This is critical for maintaining first-pass accuracy in our claim repricing services.
Storage, archival & retrieval
All claim data is securely stored, archived for compliance, and can be easily retrieved through user-friendly dashboards and digital access points.
Decisioning
Handle rejections, denials, repricing adjustments, and resubmissions efficiently. Our decisioning workflow ensures transparency and control across every stage of the claims repricing process.
Output, shipment & dashboard
We provide detailed output files, timely electronic and physical delivery options, and access to comprehensive dashboard analytics for real-time insight into repricing performance and network utilization.
Claim Repricing Solution with PPO Routing to Prevent Loss of Claims
PCH Health’s claim repricing solution is built to do more than just reduce costs, It actively prevents claim loss, ensures transparency, and supports compliance at every stage of the claims repricing process. Our intelligent PPO repricing solutions empower third-party administrators (TPAs), health plans, and cost containment companies to manage high volumes of critical claims with accuracy and speed.
Through real-time PPO routing for healthcare, our system ensures that every claim is directed to the most appropriate network, whether primary, secondary, or a cost-containment vendor, before it reaches the payer’s adjudication platform. This smart routing significantly reduces errors, denials, and rework while preserving claim integrity.
To maintain oversight and compliance, we offer built-in audit controls, detailed audit trails, and reconciliation at both the claim and file levels. These features help mitigate risk and protect revenue by ensuring no claims go unprocessed or lost in transit,a core benefit of our claim repricing services.
Our proprietary, rules-based hierarchical routing engine offers unmatched efficiency and precision. It delivers end-to-end visibility into the claims repricing process, supports payer-specific requirements, and ensures clean handoffs across all involved networks.
Here’s what our integrated healthcare repricing solution delivers:
- Network-agnostic compatibility across all payers and providers, regardless of geography or contract complexity
- Accelerated turnaround times, with 90% of repriced claims returned within the same business day
- A robust payment accuracy suite that includes pre-edits, contract validation, and COB checks
- Advanced provider and member matching that overcomes common data inconsistencies and reduces claim rejections
- Audit-ready reporting and reconciliation, supporting regulatory compliance and financial transparency
Whether you're managing domestic fee schedules, case rates, per diem rates, bundled payments, or direct provider contracts, our scalable claim repricing solution is designed to adapt to your business needs while driving measurable savings.
Overcome Data Vulnerability with Claim Repricing Solution
Reprice any network claim, regardless of contract complexity, including domestic fee schedules, case rates, per diem rates, bundled payments, direct contracts, and provider carve-outs
>98%
First-pass accuracy
100%
Automated claims repricing
<24hrs
Turnaround Time
30-40%
Savings
Claim Repricing Solution: Real-Time Insights & Reporting Dashboards
Visibility is key to improving outcomes in any claims repricing process. With PCH Health, you gain access to powerful, real-time reporting dashboards that offer detailed insights into network utilization, turnaround times, cost savings, and repricing accuracy.
Our analytics suite includes:
- Dynamic dashboards with drill-down views by payer, provider, or claim type
- Audit trail logs to ensure transparency and track claim status at every stage
- Reconciliation reports at both file and claim levels
- Network performance tracking to optimize PPO routing for healthcare
- Custom export formats, tailored to your platform or adjudication system
These tools empower you to make smarter decisions, enhance network efficiency, and maximize the ROI of your healthcare repricing solution.
Why Choose PCH Health for Claim Repricing Services?
Choosing the right claim repricing solution can make a significant impact on your operational efficiency and bottom line. At PCH Health, we go beyond basic cost reduction. We deliver intelligent, adaptive claim repricing services built for today’s complex healthcare ecosystem.
Here’s what makes us different:
- Seamless integration with national and regional PPO networks
- Smart PPO routing for healthcare, ensuring optimal claim direction and minimal leakage
- Custom rules engine tailored to your business needs and network structures
- End-to-end claims repricing process with built-in audit trails and reconciliation
- Client-first support model, with 24/7/365 responsiveness and onboarding guidance
Whether you’re a TPA, health plan, or cost containment partner, PCH Health brings the depth, scale, and flexibility to support your unique workflows, all while helping you stay compliant, competitive, and in control.
Awards and Certifications
FAQ
What is a claim repricing solution, and how does it work?
A claim repricing solution evaluates submitted healthcare claims and adjusts billed charges based on contracted rates with PPOs or negotiated terms. PCH Health uses automated tools and PPO routing for healthcare to ensure each claim is routed, evaluated, and repriced quickly and accurately, reducing costs for payers while maintaining provider relationships.
How does PCH Health ensure accuracy in the claims repricing process?
Our claim repricing services include pre-edits, validation against provider contracts, and proprietary logic to match provider and member data accurately. We also apply business rules and compliance checks to ensure the highest possible accuracy and prevent downstream denials.
Can PCH Health handle different types of contracts and pricing models?
Yes. Our healthcare repricing solutions are designed to support a wide range of contract structures, including fee schedules, bundled payments, case rates, per diem rates, direct provider contracts, and carve-outs, all within a unified, scalable platform.
How fast is your turnaround time for repriced claims?
We prioritize speed without sacrificing accuracy. Over 90% of claims are returned the same business day, ensuring timely adjudication and faster decision-making for your teams.
Is your claim repricing platform compatible with my existing PPO networks?
Absolutely. PCH Health’s solution is network-agnostic and integrates seamlessly with both national and regional PPOs. Our PPO routing for healthcare intelligently directs claims based on custom rules, priority networks, and cost-containment strategies, all configurable to your needs.