Integrating for Impact: How CMSPricer Contract Manager Transforms Your Claims Workflow

That’s a fantastic question. The real power of any SaaS Medicare repricing software isn’t just in its features, but in how seamlessly it integrates into your existing, complex operations. For Payers, TPAs, Auditing Firms, and Self-Funded Employers, integration is the key to unlocking the promised 3X acceleration.

CMSPricer’s design, including the powerful Contract Manager Claims feature, focuses on connectivity to eliminate manual data transfer and create an end-to-end automated claims process.

Three Paths to Seamless Integration

CMSPricer offers flexible methods to integrate with your core claims processing system (e.g., your claims management platform or Enterprise Resource Planning (ERP) system):

1. Real-Time API Integration (Application Programming Interface)

For organizations with high-volume, continuous processing needs, the API is the most powerful method.

How it Works: Your existing claims system connects directly to the CMSPricer API. When a claim needs to be repriced—whether it’s Medicare or a complex contract claim—your system sends the claim data in a secure, standardized format (often JSON or XML).

The Benefit: The CMSPricer Contract Manager module processes the data instantly, applies the correct contract rules (from Steps 1-3), prices the claim, and returns the accurate repriced amount and edit results in real-time. This is how you achieve true straight-through processing and the 3X speed increase.

2. Secure Batch Processing (Import/Export)

For organizations that process claims in groups or batches, this method is highly efficient and user-friendly.

How it Works: You export a batch of claims data (e.g., a CSV file) from your system. You then securely import this file into the CMSPricer platform. The system automatically runs the claims through the Contract Manager’s 5-step repricing process. Once complete, you simply export the file, which now includes the accurate repriced amounts and editing results, and import it back into your core system.

The Benefit: It dramatically reduces manual data entry errors and provides an easy-to-manage process for large claim volumes without requiring extensive technical development.

3. Manual Web Portal Entry (For Audits and Exceptions)

While the goal is automation, sometimes you need to quickly check a single claim or run an audit.

How it Works: Users can access the web-based SaaS platform to manually enter or copy and paste claim details. The Contract Manager logic is applied immediately, giving you instant repricing results.
The Benefit: Provides an immediate validation tool for auditors and managers, ensuring control and transparency over the repricing logic.

The End-to-End Workflow Transformation

By integrating, the claims workflow changes from a fragmented, manual process into a singular, automated flow:

• Claim Intake: Claim enters your core system.
• Repricing Call (Automated): Your system triggers a call (via API or Batch) to CMSPricer.
• Contract Manager Execution: The Contract Manager Claims feature identifies the provider and network, selects the correct fee schedule, and automatically applies the sophisticated rule-based sets (Step 3).
• Accurate Repricing: CMSPricer returns the accurate, repriced claim, including all necessary Medicare and editing details.
• Adjudication & Payment: Your core system uses this accurate data to instantly adjudicate and prepare the claim for payment.

Integration effectively turns your current workflow bottleneck into a high-speed automation engine, making your SaaS Medicare repricing software the most critical step in ensuring compliance and cost control.