Capitation Adjudication

A complete, end-to-end, core capitation adjudication toolset, purpose-built to support capitated payments and their underlying fee-for-service components. Easy to configure, electronic data interchange (EDI), claims processing, provider payment, and overall contract management.

Automated, Self-Service Core Administration

Product-Screenshots-CAPOur Capitation Adjudication application offers a complete suite of tools for managing delegated risk. From contract configuration and eligibility management, through adjudication and payment, it features a comprehensive capability set to administer capitated and fee-for-service payment models. Robust EDI capabilities and support for standard and proprietary data formats ensures continuity between existing systems and the partner ecosystem. We believe our applications are differentiated by their self-service functionality, which keeps overhead at a minimum.

Claims Processing

Ensure correct coding, grouping, pricing and payment is administered based on the partner contract. Automatically attach authorizations to the claim, generate letters, auto-adjudicate the claim, and track activity for compliance reporting.

Fee-for-Service Claims Adjudication

Process fee-for-service claims in addition to capitated claims, with member benefits eligibility and automated authorization and referral workflows, letter generation, and auto-claims adjudication.

Payment Reconciliation

Calculate payment and interest, and batch claims for final payment. Verify payment amount by reconciling actual payments with expected payments on a per member per month basis.

Authorizations and Referrals

Determine eligibility and automate workflows for common authorization and referral scenarios, including denials, appeals, and reviews. Automatically create letters for members and monitor compliance.

Client Success Story


You set the goal. We make it happen.

An independent physician association (IPA) client faced a challenge connecting and supporting a large, geographically dispersed provider network—comprised of 3,550 physicians and 1,300 Medicare Advantage (MA) providers—with a very diverse patient population. This IPA’s goal was to remain profitable, while improving administrative and care management efficiency in state Medicaid and Medicare programs, and to grow in market share.


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Payment Technology

A new generation of payment technology tools is needed to manage today’s complex alternative payment models. Efficient, flexible, and proven, our core payment technology processing tools are purpose-built for value-based payment models. They simplify the contract management and adjudication process for complicated reimbursement structures, including bundled and capitated payment arrangements. Support for common and proprietary data exchange formats and robust interfacing capabilities ensures a seamless integration experience with existing systems and partner ecosystems.

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Case Study

Experience Growth Through Claims Processing and Care Management

The results are in! Discover how our Capitation Adjudication solution helped an independent physician association revamp its strategic approach to Medicaid and Medicare programs and secure greater industry leadership in its mission of value-based care.

Blog Post

Payment Reconciliation and Audit Tools: The Key to Navigating the World of Capitation Contracts with Confidence

Our flexible claims adjudication solution features payment reconciliation, stop-loss reporting, and customizable claims audit tools that can help maximize your financial performance in capitation agreements.

Blog Post

Tracking Risk and Quality Scores at the Member Level: The Key to Maximizing Reimbursement in a Capitated Payment Model

We built a payment technology solution to meet the specific needs of providers and payers engaged in alternative payment models, like partial and full capitation. This helps streamline the process of risk score capture, member attribution, funds flow projection, and payment reconciliation…

Blog Post

Managing Enrollment and Eligibility Lists for Accurate Monthly Payments in Healthcare

Navigating capitation payment models can be dauting for healthcare providers and payers, especially with the constant flux of member enrollment and eligibility lists to be managed.

Blog Post

Times are Changing. Can Your Payment Processing Solution Keep Up?

Just five years ago, the majority of healthcare organizations would tell you that they needed payment technology optimized for fee-for-service (FFS) arrangements. Now, the situation is dramatically different.

Blog Post

Managing Multiple Provider Contracts and Complex Capitation Models

As value-based care models become more prevalent in the healthcare sector, the complexities of capitation models are increasing.




Manage risk more effectively and obtain greater value for every healthcare dollar.



Act on emerging opportunities to transform operations and improve financial performance.


Employers / ASOs

Recognize high-value innovation opportunities in healthcare with our help.



The right solution for your value-based journey is only a click away. Our modular technology is quickly and easily integrated into current systems and complements existing IT investments so that we can grow with you. Learn more today!

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