Benefit Plan Adjudication

Health Benefits Administration Software | Self Insurance Administration Software | Repricing Software | Claims Payment Software | Medicare Pricing Software | Benefit Plan Management software | Capitation Software | EDI software

The process of adjudicating health claims is a complex business ideally suited for automation, and VISOVA provides a solution with simplicity and power. Flexible Benefit Plan definitions allow for great control over user defined Accumulators, Copay, Coinsurance, Deductibles, Limits, and waiting periods.


VISOVA’s answer to business rule automation when managing benefit and payment determination is: Pay-Talk. It provides you with the ability to completely automate the analysis and assignment of benefits to each service line using any content on the claim, historic claims, clinical controls on the patient or any related information. Using easy to read “if/then” Boolean logic, you are able to drive VISOVA to automate the adjudication of any benefit plan. The Physician Fee Schedule Relative Value File contains additional claim edit rules that identify the follow: global follow up days applicable to evaluation and maintenance visits following a surgery; percentage reductions for team surgeries, co-surgeries, bilateral surgeries, assistant surgeries, and multiple surgeries.


Fair Health (INGENIX), Auto-Audit, Captiva, Med-Assets, RedCard, and U&C rate sources

Other cost containment and payment controls:

  • Usual and Customary rates
  • Coordination of Benefits
  • Limits on authorized services
  • High risk factors
  • Capitated and Fee for Service identification
  • Student and Dependent verification
  • Multiple surgeries
  • Bilateral procedures
  • Assistant surgeon
  • Vision
  • Dental Services
  • Anesthesia
  • Drug codes
  • PCP’s
  • Durable Medical Equipment
  • And many more