Zelis

This involves strategically planning and structuring a healthcare provider network. It considers factors like geographic coverage, provider specialties, patient demographics, and cost-effectiveness to create a network that meets the needs of the payer and its members. It's about building the right network from the ground up.

This is the ongoing evaluation of an existing provider network's performance. It analyzes factors like cost, quality, access, and member satisfaction to identify areas for improvement. This helps payers understand how well their network is functioning and where adjustments are needed.

This encompasses the activities required to keep a provider network running smoothly. It includes tasks like credentialing providers, negotiating contracts, updating provider directories, and ensuring compliance with regulations. It's the operational side of keeping the network up-to-date and effective.

These tools help members enroll in health plans. They may include online portals, mobile apps, or paper forms. The goal is to make the enrollment process easy and efficient for members.

These cards provide members with proof of insurance coverage. They're typically used at the point of service to access healthcare services.

These tools allow members to estimate the cost of healthcare services before they receive them. They may provide information on provider fees, plan coverage, and out-of-pocket expenses. This empowers members to make informed decisions about their care.

These tools help members find healthcare providers who are in their network and who meet their needs. They may allow members to search by specialty, location, or other criteria.

This refers to individualized assistance provided to members. It may include help with choosing a plan, finding a provider, or understanding their benefits.

These platforms are designed to keep members informed and engaged in their healthcare. They may offer personalized recommendations, health education resources, and communication tools.

This refers to adhering to the regulations of the No Surprises Act, which protects patients from unexpected medical bills. Zelis likely offers tools and services to help payers comply with the NSA's requirements.

This involves meeting the requirements of the Transparency in Coverage rule, which requires health plans to make pricing information available to consumers. Zelis likely offers tools and services to facilitate this transparency.

This refers to negotiating with out-of-network providers to obtain lower payment rates for services rendered.

This involves reviewing claims for errors and inconsistencies before they are paid. It helps to prevent overpayments and fraud.

This is a more in-depth review of medical bills to ensure that the charges are reasonable and appropriate.

This may involve negotiating with providers to reduce the amount of a claim.

This refers to pricing models that allow members to access care from any provider, even those outside of their network, while still controlling costs.

This is Zelis's payment platform, designed to facilitate faster and more efficient payments to providers.

This refers to the process of making payments to healthcare providers for services rendered.

This involves collecting premium payments from members or groups.

This encompasses communications related to the enrollment process, such as welcome messages, benefit summaries, and instructions for accessing care.

This refers to communications related to claims, such as explanations of benefits (EOBs) and notifications about claim status.