Eligibility & benefits
Real-time member lookups, plan details, copays, deductibles, and out-of-pocket maximums via 270/271.
Pillar · Payer
Where the network meets the claim
Clinicle for payers brings eligibility, authorizations, claims, network management, and member self-service onto the same record providers already use. Less round-tripping, fewer denials, faster decisions.
✓ HIPAA-aligned
✓ X12 EDI
✓ FHIR APIs
Payer modules
From eligibility check to remit — one workspace
Built on the same Clinicle backbone as the provider suite, so the payer and the clinic talk to the same record instead of trading paper.
Prior authorizations
Automated intake from provider chart, rules-based routing, and decision in days — not weeks.
Utilization review
Clinical criteria workflows with MCG/InterQual support, peer-to-peer queues, and appeal tracking.
Claims adjudication
837 ingestion, configurable edits, auto-adjudication, denial codes, and pend queues that explain themselves.
Remits & reconciliation
835 remits, EFT reconciliation, overpayment recovery, and clean handoffs to provider billing.
Provider network management
Credentialing, contracting, fee schedules, and a live directory members can actually search.
Member portal
Digital ID card, benefits at-a-glance, claims history, in-network search, and secure messaging.
Care management
Care coordinator queues, condition programs, outreach campaigns, and shared task lists with providers.
Cost & outcomes analytics
Total cost of care, per-member-per-month, utilization benchmarks, and provider performance scorecards.
Population health
Risk stratification, gaps-in-care, HEDIS-style measures, and targeted outreach lists.
Fraud, waste & abuse
Pattern detection across claims, outlier flagging, and an investigator workbench with audit trail.
Regulatory reporting
Filings for CMS, state regulators, and accrediting bodies generated from the same data the business runs on.
The provider-payer bridge
Why building on a clinical platform changes the math
Most payer systems start from billing data. Clinicle starts from the chart. That lets eligibility, authorization, and adjudication see the clinical context they’ve historically had to ask for — and gives providers a clean, structured way to answer.
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Fewer round-trips between provider and payer on authorizations and denials
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Higher clean-claim rates when the chart and the claim share a schema
Live
Eligibility and benefits resolved at scheduling time, not at the front desk
Open
FHIR + X12 APIs for clearinghouses, TPA partners, and internal data lakes
Bring your payer ops onto the same record
Talk to the Clinicle payer team about pilots: a single provider group, a specific line of business, or a defined member population.