Zelis Out-of-Network Solutions offer a multifaceted approach to controlling out-of-network (OON) healthcare expenses. The suite includes:

• Expert Negotiations: Combining human expertise with advanced technology to identify and negotiate high-quality savings on OON claims after services are rendered.
• Network Pricing: Applying contracted discounts to OON claims by leveraging Zelis' extensive networks and over 60 local, national, and specialty network partners, providing access to more than 800,000 providers nationwide.
• State-Based Pricing: Pricing OON claims in accordance with federal and state-level regulations to help avoid state arbitration occurrences, including pricing based on state-specific requirements and provider education.
• NSA and TiC Solutions: Providing tools to comply with federal surprise billing regulations, including pricing, negotiations, Independent Dispute Resolution (IDR) support, and transparency.
• Member Bill Support: Assisting members in navigating OON balance bills, reducing financial stress, and improving their overall experience.

By integrating these services, Zelis enables health plans to optimize financial performance while balancing risk and enhancing member satisfaction.

Key Features & Benefits

• AI-Powered Dynamic Optimization: Utilizes artificial intelligence to route claims to the most appropriate savings channels, ensuring quality and cost-effectiveness.
• Customizable Solutions: Allows tailoring of services to individual employer groups, service types, claim types, and member levels, aligning with specific organizational goals and preferences.
• Provider Collaboration: Builds trust and cooperation with providers at local, regional, and national levels, facilitating effective OON pricing efforts.
• Regulatory Compliance: Assists in meeting regulatory requirements for the No Surprises Act (NSA) and Transparency in Coverage (TiC), ensuring adherence to federal guidelines.
• Enhanced Member Experience: Provides support to members in understanding and managing OON bills, reducing financial strain and improving satisfaction.