Healthcare claim pricing is complex

With provider contracts, claim data, federal and state regulatory requirements and business policies all contributing to the claim pricing process, it can be challenging to coordinate healthcare payment accuracy and timeliness.

Optum® Claim Pricing solutions can help you achieve more accurate claim pricing through automation, enhancing auto-adjudication rates and creating pricing transparency. Our comprehensive suite of pricing solutions includes:

EASYGroup™, an integrated grouping and pricing engine that automates the accurate editing, grouping and pricing of claims across multiple care settings
Payment System Interface (PSI), a web-based claim pricing platform that helps create pricing transparency and keeps you compliant with current regulations
Application Managed Services (AMS), a dedicated team that provides ongoing support to help you make the most of your claim pricing software

Achieve more accurate, efficient claim pricing

Optum Claim Pricing solutions drive first-pass adjudication and create greater pricing transparency.

Flexible

Our Claim Pricing solutions integrate with any claim adjudication platform and can be deployed onsite or via the cloud.

Transparent

Our pricing worksheets share step-by-step pricing calculations for each claim, ensuring pricing accuracy and creating transparency.

Experienced

Every year, more than 80% of Medicare Advantage facility claims are processed using Optum Claim Pricing solutions.*

Improve claim pricing accuracy with automation

Optum EASYGroup automates the process of accurate claim editing, grouping and pricing across multiple care settings, enhancing auto-adjudication rates and helping reduce provider abrasion.

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Create greater pricing transparency

Payment System Interface is a web-based claim processing platform that enables individual claim review, batch processing, advanced modeling, analytics and reporting. PSI helps health plans across all lines of business create greater pricing transparency, improving pricing accuracy and provider relationships.

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Optimize your pricing solutions with Application Managed Services

Maximize your organization’s investment with Application Managed Services. We provide access to a dedicated AMS support team to help you with the entire PPS process — from installation, validation and maintenance to regulatory insights and ongoing support.

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Frequently asked questions about claim pricing

Health plans can manage the complex and ever-changing rules that govern healthcare claims by using automated systems capable of applying industry, regulatory and contractual requirements at scale. These systems can review claims against millions of rules to identify inconsistencies and correct errors across commercial, Medicare and Medicaid lines of business.

By relying on automation with human oversight rather than manual review, health plans can help streamline claim adjudication, reduce administrative burden and improve claims payment accuracy so that claims are processed consistently and in alignment with current policies.

Read our guide on technology solutions that automate and scale claim pricing.

Claims payment accuracy can be strengthened by using automated editing, grouping and pricing workflows that evaluate claims before payment is issued. These tools assess clinical logic, coding practices, contractual terms and policy requirements to validate that each claim is appropriately billed and priced.

Automating these steps can help reduce the likelihood of errors, minimize rework and support accurate payment the first time a claim is processed. This leads to more reliable financial outcomes and a significant reduction in unnecessary spend.

Learn how to create a framework that drives claim pricing accuracy on the first pass.

Health plans can improve adjudication rates by adopting automated review processes and maintaining up‑to-date regulatory and policy content within their claims workflows. These systems enable more claims to be processed without manual intervention by applying consistent, rules‑based logic.

As a result, claims move through the system faster, exceptions decrease and the end‑to-end payment cycle accelerates. Higher auto-adjudication rates not only improve operational efficiency but also reduce administrative costs and enhance the overall provider and member experience.