Corporate Office
USA
299 S. Main Street
Suite 1300
Salt Lake City, UT 84111
Suite 1300
Salt Lake City, UT 84111
Chennai - Tower I
CeeDeeYes Tyche Towers,
Block-1 3rd Floor, Perungudi Bypass Rd, Perungudi,
Chennai - 600096
Block-1 3rd Floor, Perungudi Bypass Rd, Perungudi,
Chennai - 600096
Chennai - Tower II
4th Floor, IIFL TOWERS
MGR Main Rd,
Perungudi, Chennai - 600096
MGR Main Rd,
Perungudi, Chennai - 600096
Villupuram
No 9, Viswalingam Layout
Villupuram,
Tamil Nadu – 605602
Villupuram,
Tamil Nadu – 605602
Payer Operations Support
Clinical Coding Intelligence. Payment Integrity. Risk Adjustment Precision.
End-to-end payer operations support including credentialing, risk adjustment, payment integrity, appeals, member services, analytics delivered by professionals who understand operations.
Complete service depth: credentialing, risk adjustment, payment integrity, appeals, member and provider inquiry, and analytics with performance benchmarks, financial modeling, and engagement approach.
Data & Analytics Platform with real-time Power BI dashboards for payer executives: risk adjustment trending, claims audit metrics, HEDIS performance, credentialing status, appeals pipeline, and member analytics in a unified view.
Credentialing backlogs are one of the most common operational failures in health plans. Each delayed credentialing file represents a provider who cannot be paid, a directory entry that is inaccurate, and a network adequacy risk under CMS rules. Most plans run 60 to 90-day turnaround cycles. Delegated credentialing oversight adds another layer of complexity that internal teams struggle to maintain at scale.
What AnnexMed Delivers?
Impact Area
Typical Plan Outcome
Initial credentialing for new network providers
Provider directory accuracy validation and updates
Re-credentialing cycle management with zero missed deadlines
CMS network adequacy compliance monitoring
CAQH ProView profile maintenance and attestation management
NPI, taxonomy, and specialty data reconciliation
Primary source verification across all required sources
Roster management for delegated entities
Committee preparation and credentialing file packaging
Termination and status change processing
Delegated credentialing oversight and audit support
Network enrollment with commercial and payers
Sanction monitoring and adverse action tracking
Continuous compliance monitoring and regulatory risk
Team and Certifications
Credentialing specialists trained in NCQA credentialing standards, CMS network adequacy requirements, and state-specific credentialing rules. Teams are organized by plan type to ensure regulatory context is maintained across Medicare Advantage, Medicaid MCO, commercial, and TPA programs.
KPIs We Track
Performance Metric
AnnexMed Target
Initial Credentialing Turnaround
15 to 30 days (vs. industry 60 to 90 days)
Re-Credentialing Deadline Compliance
100% on time, zero missed cycles
Provider Directory Accuracy
98%+ (vs. CMS threshold 95%)
CAQH Attestation Completion Rate
100% within required windows
Delegated Entity Audit Findings
Zero deficiencies on oversight audits
Ideal Use Cases
- Credentialing backlogs delaying payments
- Preparing for CMS network adequacy audits
- Strengthening CMS compliance readiness
- Rebuilding provider directory after sanctions
Risk adjustment is the highest financial exposure area for Medicare Advantage plans. A 1% error in RAF can mean $5M to $20M in annual exposure. RADV audits now impose direct financial penalties for unsupported diagnoses. CMS V28 model changes are restructuring HCC mappings mid-cycle, requiring teams to simultaneously manage both models. HEDIS chart review requires clinical reviewers at measurement season scale that is impossible to sustain with internal headcount.
What AnnexMed Delivers?
Risk Adjustment Programs
HEDIS Chart Review
Prospective risk adjustment review
Encounter-based HCC identification before year close
NCQA-trained abstractors
IRR-qualified teams ensuring abstraction accuracy
Retrospective chart review
Retrospective diagnosis capture with medical record validation
Medical record retrieval and abstraction
End-to-end retrieval, intake, and chart abstraction
Gap closure programs
Member-level HCC gap analysis and outreach coordination
Hybrid measure support
Across applicable HEDIS measures
RADV audit support
Documentation review, defensibility scoring, and response preparation
Administrative data supplementation
Validation and supplemental data integration
V28 transition support
Dual-model coding to manage CMS transition year requirements
Star Rating optimization
Measure prioritization and gap analysis
Encounter data submission QA
RAPS and EDGE submission accuracy review
Data submission accuracy support
Validation, reconciliation, and compliance readiness
Team and Certifications
CRC (Certified Risk Adjustment Coder) certified specialists for HCC coding. NCQA-trained abstractors for HEDIS chart review with documented IRR scores above 98%. Teams maintain knowledge of CMS V28 model changes, RADV audit methodology updates, and NCQA HEDIS Technical Specifications.
KPIs We Track
Performance Metric
AnnexMed Target
HCC Capture Accuracy
15 to 30 days (vs. industry 60 to 90 days)
HEDIS Inter-Rater Reliability (IRR)
98%+ (vs. NCQA minimum 95%)
RADV Audit Documentation Support Rate
100% charts with valid documentation
Retrospective Revenue Identified
$15M to $40M for mid-sized MA plans
Measurement Season Throughput
Scale to volume within 2-week notice
Ideal Use Cases
- Medicare Advantage plans nearing RADV audits
- Managing V28 transition with dual coding
- Missed HEDIS cycles or low Star Ratings
- MCOs needing seasonal chart review capacity
National estimates place 3 to 5% of claims as containing coding errors that result in overpayment. For a plan processing $2B annually, that is $60M to $100M in potential leakage from unbundling, upcoding, duplicate billing, modifier misuse, and medical necessity failures. Most plans lack the internal clinical reviewer capacity to conduct systematic pre-payment review or post-payment audit programs at meaningful scale.
What AnnexMed Delivers?
Pre-Payment Review
Post-Payment Audit
High-risk claim flagging before payment release
Retrospective audits by provider and facility
AI detects unbundling, upcoding, modifier misuse
Overpayment identification and recovery demands
Medical necessity review against clinical criteria
Fraud, waste, and abuse pattern analysis and referral
DRG validation by CCS-certified specialists
Coordination of benefits and subrogation claims
Outpatient edit logic review and refinement
Edit library development and maintenance
Provider profiling for outlier identification
Audit findings with financial impact reporting
Team and Certifications
CCS (Certified Coding Specialist) and CPC (Certified Professional Coder) credentialed reviewers for DRG validation and clinical coding audit work. Claims audit analysts with payer-side experience in edit logic, overpayment methodology, and recovery demand processes. AI platform integration for pattern-based flagging before manual review and continuous audit performance improvement insights.
KPIs We Track
Performance Metric
AnnexMed Target
Overpayment Recovery per Claim Reviewed
$3 to $8 (vs. industry average $1 to $3)
Pre-Payment High-Risk Flag Accuracy
90%+ actionable findings on claims
Post-Payment Audit Cycle Time
Findings delivered within agreed SLA
Annual Overpayment Exposure Reduced
$18M–$50M recovery for $1B–$2B plans
Edit Logic Refinement Rate
Ongoing, with quarterly review cycle
Ideal Use Cases
- High claim volumes, limited pre-payment review
- Post-payment audits by provider or procedure
- Plans building or refining claims edit libraries.
- Plans identifying FWA patterns, need audit support
Provider appeal volumes are rising as payers tighten UM criteria and prior authorization rules. Each appeal requires clinical review, documentation retrieval, and coding validation with a compliant response within timelines. Backlogs increase compliance risk under CMS and state regulations. Most plans cannot handle surge volumes without creating multi-week delays.
What AnnexMed Delivers?
Impact Area
Typical Plan Outcome
First-level appeals
Clinical review and initial determination
Medical record retrieval
From provider offices, hospitals, and facilities
Second-level appeals
escalated review with senior clinical staff
Clinical documentation management
Intake, review, and indexing of records
External appeals support
Documentation preparation for IRO submission
Coding validation
Against retrieved clinical documentation
DRG dispute resolution
Coding validation against medical record
Regulatory-compliant responses
Appeal letter drafting and submission support
Medical necessity defense
Clinical criteria application and documentation
Turnaround governance
SLA tracking and performance management by appeal type
All claim appeal types
Professional, facility, and ancillary appeals
Appeals analytics and reporting
Volume tracking, outcomes, and denial root cause analysis
Team and Certifications
Clinical reviewers with RN credentials for medical necessity determinations. Certified coders for DRG validation and coding dispute resolution. Appeals coordinators with payer-side regulatory training on CMS and state-specific timeframe requirements for expedited, standard, and IRO appeals.
KPIs We Track
Performance Metric
AnnexMed Target
Appeals Regulatory Compliance
100% within CMS and state timelines
Expedited Appeal Turnaround
100% within 72-hour CMS timelines
Standard Appeal Turnaround
Within 30/60-day plan requirements
Documentation Retrieval Completion
95% within 10 business days
First-Level Upheld Rate
Tracked by denial category trends
Ideal Use Cases
- Growing appeals backlogs increasing risk
- Preparing for CMS audit readiness on appeals
- High DRG dispute volumes from providers
- Surge capacity for benefit year or UM changes
Payer contact centers handle a far wider range of inquiries than typical call center operations. Staff need to understand coding, benefits design, claims adjudication logic, credentialing status, and authorization requirements to resolve inquiries at first contact. Generic call center staff without payer domain knowledge drive repeat contacts, escalations, and provider abrasion. Open enrollment and benefit year transitions create volume spikes that cannot be absorbed without scalable surge capacity.
What AnnexMed Delivers?
Member-Facing Support
Provider-Facing Support
Benefits explanation and coverage clarification
Claims status and reimbursement inquiry resolution
Claims status and adjudication inquiry resolution
Credentialing status and enrollment inquiry handling
Prior authorization status and process guidance
Authorization submission guidance and status tracking
Grievance intake and documentation
Remittance advice and ERA inquiry support
Coordination of benefits inquiry handling
Contract and fee schedule inquiry routing
Open enrollment support and plan comparison assistance
Provider portal registration and navigation support
Language access support coordination
Escalation triage for complex billing and coding disputes
Team and Certifications
Inquiry teams trained in payer operations fundamentals: ICD-10 and CPT coding basics, claims adjudication logic, benefits design terminology, credentialing processes, and authorization requirements. Teams are not script-only. Staff are trained to resolve rather than transfer, reducing repeat contact rates and provider abrasion. Seasonal surge capacity is pre-planned, not reactive.
KPIs We Track
Performance Metric
AnnexMed Target
First Contact Resolution Rate
85%+ member, 80%+ provider inquiries
Average Handle Time by Inquiry Type
Tracked against plan benchmarks
Repeat Contact Rate
Reduction targets set at onboarding
Surge Capacity Deployment Time
Additional teams deployable in 2 weeks
Provider Satisfaction Score (Post-Call)
Quarterly tracking and improvementa
Ideal Use Cases
- High provider abrasion from credentialing delays
- Preparing for open enrollment volume spikes
- Separate member and provider contact functions
- Mid-year benefit changes needing surge support
Most health plans have data but lack the analytical infrastructure to make it operationally useful. Risk adjustment trending, HEDIS performance, credentialing pipeline status, appeals aging, and claims audit results exist in separate systems with no unified view for executive decision-making. Without real-time visibility into operational KPIs, plan leaders are managing by lagging indicators rather than leading indicators that allow intervention before financial or compliance problems compound.
What AnnexMed Delivers?
Impact Area
Typical Plan Outcome
Risk adjustment
HCC capture rate, RAF trending, gap closure progress, and RADV readiness score
Power BI dashboards
Drill-down by provider, member, region, product
Payment integrity
Pre-pay flag volume, post-pay recovery, overpayment trending by category
Automated KPI alerts
Alerts when performance drops below thresholds
HEDIS
Performance by domain, IRR scores, abstraction progress
Financial modeling
Modeled impact by service pillar and outcomes
Credentialing
Pipeline aging, turnaround by type, directory accuracy, delegated status
Benchmarking insights
Compared to national and plan-type benchmarks
Appeals
volume by type, turnaround compliance, outcome rates, denial root cause trends
Coding analytics
Accuracy trends and productivity performance insights
Member and provider operations
Inquiry volume, FCR rates, repeat contact rates, escalation trends
Data integration
Integrated across EMR, claims, enrollment systems
Platform
Analytics powered by AnnexMed’s advanced data and analytics platform. Built on Microsoft Power BI with payer-specific data models, KPI governance frameworks, and pre-built dashboard templates for each service pillar. Dashboards are available as embedded views for plan executives or as standalone reporting delivered on agreed cadences.
KPIs We Track
Performance Metric
AnnexMed Target
Dashboard Refresh Cadence
Daily KPIs, real-time critical metrics
Alert Response Time
Threshold alerts within 24 hours
Reporting Accuracy
99%+ accuracy, source data validated
Executive Report Delivery
Monthly reviews with YTD trends
Custom Report Turnaround
Ad hoc requests done in 3 days
Ideal Use Cases
- Unified visibility across payer operations
- Rebuilding reporting after system transitions
- Unable to answer ops without multiple systems
- Preparing for CMS audit readiness reviews
Full-Service Payer Operations Partnership
AnnexMed can engage across one pillar or all six simultaneously. Most health plans start with the highest-impact function and expand as performance results confirm. The following engagement structure applies regardless of which pillars are in scope.
STEP 1
Payer Operations Assessment
No-cost assessment. We identify your highest-impact pillar, model the financial opportunity, and recommend an engagement structure with projected outcomes clearly.
STEP 2
Onboarding and Go-Live
Teams onboard within 2 to 3 weeks. Workflows, reporting lines, and SLAs are clearly established before go-live. No disruption to existing operations whatsoever.
STEP 3
Results and Expansion
Measurable outcomes within 60 to 90 days. Expand to additional pillars as results confirm. All six pillars can also be engaged from day one with flexible deployment options.
Get a payer operations assessment
We conduct a no-cost Payer Operations Assessment identifying your highest-impact pillar, modeling financial opportunity, and providing a recommended engagement with outcomes
Trusted by 100+ Healthcare Providers | AAPC, AHIMA & AAHAM Certified | SOC 2 Type II | All 50 States
Proven RCM expertise. Delivered at scale.
For over 20 years, AnnexMed has delivered RCM solutions nationwide, combining expert billing, coding, and AR support to drive measurable results and growth.
- 20+ years of proven healthcare RCM experience
- 1,500+ professionals supporting billing, coding & AR
- 500+ certified coders across multiple specialties
- 99%+ compliance with HIPAA and security standards
- All 50 states served with consistent, scalable operations
