Solutions
Claims data management for health plans
Claims data management, for a health plan, means every claim resolves to the right member, provider, location and contract in every system that touches it: core administration, payment integrity, finance and the data warehouse. Gaine HDMP links each claim to those mastered records, finds the duplicates, and sends each system only the change it needs, with the evidence.
Request a demoHow a change reaches each system
$300 million in unreconciled claims reconciled, clearing the claims backlog, at one health plan. Read how →
Three places claims come apart
The records behind every claim
A claim is only as clean as the member, provider, location and contract it points to. Gaine resolves those records first, so every system gives the claim the same answer.
Explore →Unreconciled claims and resubmissions
Claims that cannot be matched wait, providers resubmit, and the backlog compounds. One health plan reconciled $300 million of them with Gaine HDMP and cleared its backlog.
Explore →Beside your clearinghouse
Your clearinghouse moves claims and core administration pays them. Gaine keeps the records they depend on in agreement, and takes no part in transmission.
Explore →
How claims and changes move
- Claims in: from core administration, or loaded into your data lake by your own processes and read by Gaine through a data share, or by file.
- Changes out: Gaine has built direct API connectors for HealthRules Payer, Facets, QNXT and EZ-CAP. Other systems receive reconciled change files through your own change control, event notifications, or Gaine’s platform API.
- Analysis: your warehouse or lakehouse receives the reconciled records one way.
Questions
Is Gaine a clearinghouse?
No. A clearinghouse transmits and edits claims between providers and the plan. Gaine keeps the member, provider, location and contract records those claims point to in agreement across your systems, and links each claim to them. It does not transmit or adjudicate claims.
How does Gaine improve claims reconciliation?
It resolves the records first, so every claim has one right member, provider, location and contract to point to. It then recognizes duplicates and resubmissions, and sends each system only the change it needs, with the evidence.
Does Gaine replace our claims system?
No. HealthRules Payer, Facets, QNXT, EZ-CAP or your own system keeps adjudicating. Gaine has built direct connectors to those four, and delivers change files to the rest.
Does Gaine detect fraud?
Detection stays with your payment-integrity tools and team. Gaine supplies the resolved member, provider and claim records they work from, so a pattern is not hidden by a duplicate or a mismatched ID.
How do claims reach Gaine?
From core administration, or from your data lake through a data share after your own processes load them, or by file.
Who runs it after go-live?
Your team. Stewards work the exceptions, not the routine flow. Help from Gaine or your systems integrator is available if you want it; neither is required.