Providing comprehensive clinical editing content

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KnowledgePacks supply the clinical foundation of rules and logic necessary to execute a specific payment policy or guideline. Each rule has a set of clinical data and rationale associated with it. The automated result is an edit: a recommendation to review, modify, deny, or allow a specific claim line.

Choose which ClaimsXten rules to implement based on your business needs. KnowledgePacks are defined by areas of interest, to align with your specific needs and lines of business. Being able to select and implement a smaller targeted set of rules enables you to define the scope of your implementations and may help you reduce costs. Studiomaca clinical experts develop and distribute quarterly KnowledgePack updates, so the number of rules continues to grow and drive continuous value across all of your payment policies.

Available KnowledgePacks include:

  • Code Auditing KnowledgePack Access a robust set of rules for professional claims, sourced to the American Medical Association (AMA) and numerous specialty societies.
  • Code Auditing Premium KnowledgePack Gain insight from the insight of historical claims data across dates of service and provider in order to address the latest industry trends.
  • CMS-Sourced KnowledgePack Reference all CMS guidelines including medically unlikely edits as well as durable medical equipment (DME) claims and other coverage guidelines.
  • Facility KnowledgePack Automate outpatient facility claims auditing with standardized and defensible coding guidelines.
  • National Coverage Determination, Local Coverage Determination (NCD/LCD) KnowledgePack Implement the CMS Guidelines for national and local coverage determinations for commercial and Medicare, professional or facility claims and region.
  • Waste and Abuse KnowledgePack Identify wasteful payments, billing errors and abusive billing.
  • Custom Rules KnowledgePack Build unique rules to address your individual payment policies.