Efficient claims processing is essential for health plans aiming to deliver accuracy, compliance and member satisfaction. Fusion CX provides comprehensive core claims processing solutions that streamline workflows, reduce errors and accelerate reimbursements.
Our end-to-end services include claims adjudication, re-pricing, payment reconciliation, adjustments and denial management, delivering timely and compliant outcomes. By combining AI-driven automation, data validation and real-time tracking, we help health plans improve accuracy, reduce administrative costs and enhance operational efficiency, starting with eligibility verification at intake.
With more than 22 years of experience, Fusion CX pairs advanced technology with deep industry expertise to deliver seamless claims management. We help health plans process high claim volumes quickly and transparently, strengthening collaboration through provider engagement, improving member satisfaction and achieving measurable efficiency gains. For payer-side claims inquiries, see our claims support services.
Back-office claims work for health plans, covering every step between a claim arriving and the books balancing.
Claims and attachments checked for completeness, member eligibility and coding errors at intake, so fewer claims pend or return later.
Claims reviewed and adjudicated accurately against health plan guidelines and payer policies, reducing the risk of errors and rework.
Adjustments processed when needed for accurate settlements to members and providers, with clear communication throughout the adjustment process.
Claims re-priced against contracted provider rates for fair, timely reimbursements, with streamlined steps that cut administrative overhead.
Payment disputes between health plans, members and providers resolved promptly and transparently, in line with contractual agreements.
Payments reconciled against claims, reimbursements and provider agreements, with discrepancies resolved quickly to protect financial integrity.
Support for HCC coding documentation and reporting of risk adjustment factors, helping health plans submit accurately and on time.
Denied claims tracked, categorized by root cause and routed for correction or appeal, so recurring denial patterns get fixed at the source.
Core claims work is a production operation. Here is how we keep inventory moving and accuracy high as volumes change.
Plan-specific procedures built from your benefit configuration, provider contracts and payer policies, then signed off by your team before go-live.
Daily inventory counts and aging buckets for every queue, with claims nearing prompt-pay deadlines and high-dollar claims always worked first.
Quality analysts audit processed claims for payment and procedural accuracy, with extra review on high-dollar and complex claims.
Adjustments, disputes and denials trended weekly and traced to configuration, contract loading or intake issues, then shared with your team.
Omind products support every claims team. Processors and auditors stay responsible for every payment decision.
Automates audits and compliance checks on claims-related interactions, supporting regulatory adherence, claims accuracy and high service quality across every team.
GenAI voice agents for claim status inquiries, eligibility checks and simple issue resolution, freeing processors to focus on adjudication work.
Voice harmonization and real-time noise cancellation improve clarity and efficiency on provider calls about adjustments, disputes and re-pricing.
A claims operation with the expertise, controls and scale a regulated health plan needs.
One team covers the claims lifecycle, from submission and adjudication to reconciliation and adjustments.
Automation and AI-driven tools streamline claims work, reducing errors and improving turnaround times.
Claims adjudicated accurately and re-priced according to contractual agreements, for accuracy and efficiency.
Processing aligned with healthcare regulations, reducing the risk of errors and maintaining financial integrity.
PHI handling, access controls and audit trails on every workflow, with PCI DSS and ISO/IEC 27001:2022.
Claims capacity and business continuity across 40+ delivery centers, so backlogs do not build during peaks.
What happened when health plans and healthcare companies handed operational support to Fusion CX.
Tell us about your claim volumes, platforms and backlog. A healthcare operations specialist will follow up with a scope, ramp plan and pricing.
Guides for health plan and claims leaders weighing how to run and outsource claims work.
The questions health plans ask us most often about outsourcing claims processing.
Fusion CX offers claims adjudication, claims re-pricing, payment reconciliation, claims adjustments, payment dispute resolution, denial management and HCC coding support to ensure timely and accurate claims processing. Health plans can outsource the full claims operation or specific queues such as adjustments or re-pricing.
We use advanced technology to automate and streamline the adjudication process, with plan-specific procedures that keep decisions consistent with payer policies. Intake checks catch missing data early, and quality audits confirm payment and procedural accuracy so errors are corrected before they repeat.
Fusion CX reconciles claims payments to ensure accuracy, consistency and compliance with provider agreements. Discrepancies are identified and resolved quickly, and their causes are documented, so health plans maintain financial integrity and providers trust the payments they receive.
Yes. We provide HCC coding and reporting support to ensure accurate documentation of risk adjustment factors and timely submission for compliance and reimbursement purposes. Our teams work within your coding guidelines and review processes.
Core claims processing is the back-office work of adjudicating, adjusting, re-pricing and reconciling claims. Claims support focuses on the conversations around those claims, such as status inquiries and payment questions from members and providers. Many health plans use Fusion CX for both, connected on one record.
Fusion CX combines advanced technology, automation and decades of healthcare expertise to deliver efficient, compliant and accurate claims processing. HIPAA-compliant workflows and capacity across 40+ delivery centers help health plans keep inventory moving through volume peaks.
