Payer Services

Streamline your business operations for enhanced customer service


Dynamically changing Healthcare reforms are compellingpayers to re-engineer their business processes and models for sustainable operational excellence while ensuring excellent quality patient care. Enhancing customer communication, reducing the costs and streamlining the processes are key concerns for healthcare payers. Our innovative payer solutions enable you to derive operational excellence and maximize customer service for healthy patient experience and relationship.

Datamatics offers a wide range of payer services and solutions covering Pre-Adjudication, Adjudication, Post Adjudication,Medicare Risk Adjustment, and Data Management for major HMO, PPO and Indemnity to government sponsored plans like Medicare, Medicaid, Workers' Compensation etc.


  • Reduction in turn-around-time
  • Getting it First time right ( FTR) 99% + times
  • HIPAA compliant
  • Near shore, Offshore and Onsite capabilities 
  • Flexible engagement models to reduce total cost of operations
  • Scalability with dedicated delivery centers to manage businesses

Our Services

Mail Room Services

Our dedicated mailroom services help healthcare payers to lower administrative costs and reduce waste. Leading healthcare payers leverage Datamatics’ rich experience in mailroom management. Our unique domain-specific expertise guarantees hassle-free mailroom operations; customized, cost-effective solutions (including a detailed mail report); and competitive advantage through exceptional processing speed and accuracy.

Our comprehensive services include:

  • Receiving, recording, and sorting incoming mails
  • Delivering mails to relevant departments/individuals
  • Acknowledging receipts
  • Scanning, Indexing and Data entry
  • Collecting mails/couriers from individuals and departments
  • Recording outgoing mails
  • Dispatching outgoing mails


  • More than 144 million claims processed
  • More than 450 million images handled
  • 135 million pages scanned
  • More than 50 billion characters captured

Pre-Adjudication Services

Datamatics’ Pre-Adjudication solution helps to increase adjudication; first pass rates reduce cost and enhance overall consumer service. Our robust proprietary system are capable of handling UB/CMS 1500/Dental/Vision claims along with the EOB/additional information. Datamatics' proprietary tool iQsystem integrates with the OCR to provide efficiency and accuracy. We also provide EDI to image conversion for the clients. 


With its unique automation based business processing, Datamatics leverages on its high automation indices in processes to provide accurate, fast and secure solutions for its clients. 

With HIPAA compliant processing, we provide:

  • Scalability
  • Domain led delivery
  • Stringent service level adherence
  • Stringent Quality monitoring mechanism
  • Systemic  system validations & flags
  • Accuracy leading to reduction in cost of poor quality (COPQ)

Adjudication Services


Reducing the cost and time required to adjudicate the claim forms with minimal errors are key concerns for healthcare payers. Datamatics' Claims Adjudication team is acquainted to work with multiple platforms, ensuring efficient claims processing, faster settlements and lower processing cost per claim thereby benefiting healthcare payers.


The challenge of matching member/provider to ensure that accuracy of payments has been a never-ending concern for healthcare. With Datamatics expertise in member and provider matching, your enterprise will experience dramatic improvement in accuracy of payments for the eligible members to the right providers, leading to reduction in errors and costs.


  • Better turnaround time
  • Stringent SLA driven delivery
  • Quality promise of greater than 99%
  • Reduction in rework costs
  • Expertise in member-provider matching

Provider Maintenance

Datamatics offers innovative solutions for provider maintenance that enables you to track and speed up the provider enrollment process, ensuring provider credentials are updated on real-time basis. We have a dedicated team working on claims routed for provider matching. Our solutions enable seamless editing and updating of provider credentialsin the core adjudication system.


  • Reduction in turn-around-time by 33%
  • Error rates lesser than 0.5%
  • Reduction in rework costs

Member Enrolment

Datamatics’ team of skilled experts is proficient in managing new enrollments and change requests by leveraging its own robust proprietary member enrollment system. Our system generates the HIPAA compliant 834 EDI files which are then uploaded to the payers system for further processing. We support the payers by helping them to scale upduring the open enrolment season for handling huge volumes. Datamatics also supports enrollment on the client systems.


  • Platform agnostic operations
  • Flexibility to manage sporadic volumes in open season
  • Safe and secure processing methodologies
  • World class data security practices

Medicare Risk Adjustment


Datamatics' comprehensive HCC Risk Adjustment services are designed to ensure CMS compliance, accuracy of coding of your medical recordsand sustainable growth. Our coders are Certified Clinical Coders (CPC and CCS) and well-trained on the Claims Data Validation, Part C (HCC) and Part D (Rx HCC) Coding.We also offer highlighting of key coding and documentation errors for provider education.


  • Team of Domain experts (CPC Certified Coders)
  • Experienced coders with minimum of 2 year experience
  • Stringent quality control
  • System validated checker mechanism
  • Reduction in coding processing time

Health Insurance Exchange

Datamatics Health Insurance Exchange solutions enable Payers to attract new customers and retain the existing ones. Our Health Insurance Exchange solutions are built on Microsoft as well as Open Source platforms leveraging our expertise in IT. By implementing Datamatics’ Exchange solutions, individual insurance buyers can select plans by comparing benefits, prices and providers information. Also, employers can move from ‘Defined Benefit’ to ‘Defined Contribution coverage' providing better control and clarity on their plans coverage costs.

Datamatics helps its clients to digitally empower their existing Health Insurance Exchanges by leveraging our expertise in the latest digital technologies, viz.  Analytics, Mobility, Cloud, Social Computing. Datamatics extensively works with global health insurance carriers to provide holistic services which include portal solutions, legacy modernization, system integration, member enrollment, eligibility verification, etc.


  • Robust, modular and futuristic setup, demanded by the market
  • Cost-effective operations through optimal ‘Onsite Offshore Model’ with minimal deployment time
  • ITIL based Application Management framework for ‘near 100%’ HIX availability
  • Legacy application modernization, CRM and System Integration for better consumer orientation
  • Reduced risk factor by gaining insights in real time
  • We get much more attention from Datamatics Team as a third party service provider. Our other vendors are not as supportive and focused.

    Gate Gourmet
    Gate Gourmet
  • We are very pleased with the quality of service the Datamatics team continually provides. Datamatics has consistently made extra efforts to assist us with the sometimes difficult requirements and helping us to complete our projects on time.

  • We have built a partnership with the SharePoint technical team of Datamatics over last three years. Having a dedicated SharePoint team from Datamatics, that truly understands our environment, our project plans. Datamatics delivery capabilities have enabled the Jet Intranet portal to be accessible 24X7.

    Jet Airways
    Amol Baadkar, Manager Communications - Jet Airways (India) Ltd.
  • We value Datamatics’ creative thinking, responsiveness and deep understanding of technology. This has helped our Application development initiatives with data visualization for customer insights.Datamatics collaborates with us in several areas including ideation and provides recommendations on application development, ways to streamline our business, creation of new tools for our research applications, as well as on programming and data production services in support of our day-to-day business. Datamatics has been a reliable, go-to partner delivering with quality for several years. We look forward to growing our relationship in the future.

    Carol Fitzgerald, President & Co-Founder - BuzzBack
  • Datamatics has provided us the best Business Analytics product – nSights. It has empowered us to stay on top of our business intelligence requirements. The seamless implementation and upgradations done by the teams from time-to-time, while least affecting our business-as-usual have held us in awe of the support and development teams.

    We have been working with the Datamatics team for many years and want to sincerely appreciate the team for their quick response to the issue resolution and efficient services.

    Looking forward to continuing to work with the Datamatics team in the years ahead.


Test Automation for Giant Australian Healthcare insurance provider

A Healthcare Insurance giant needed test automation for their back office applications comprising various modules including member enrolment, claim processing and compliance reporting. Datamatics deployed DARTENIUM, its state-of-the-art automation framework for intensive multiple browser regression testing. The client was able to react quickly to changing business needs along with 40% reduction in maintenance& support costs and 60% improvement in test coverage on all browsers.

ERP Migration for a Homeopathy Giant

A Homeopathy giant wanted to upgrade their ERP as their existing system was built on obsolete technology. Datamatics successfully migrated the client’s traditional ERP system to the latest ERP version thereby ensuring that all migrated application were running seamlessly across all its 110 clinics. The solution helped the client realize significant cost savings along with 30% improvement in the performance of the application.

Healthcare Giant Explores New Business Opportunities with Improved Decision Making

A large US revenue cycle management company was facing strategic problems with respect to segmenting the market and cross-selling their products. Datamatics came up with a workflow-based solution devised to effectively convert unstructured data into a digital format and feed it into the BI system using IBM’s Cognos Express platform featuring automated on-the-go information access. The solution helped the client realize enhanced decision making which was more prompt and fact based than ever before. Subsequently, generating new business opportunities for the client as well as cross-sell services to the right existing customers

Test Automation for Giant Australian Healthcare insurance provider
ERP Migration for a Homeopathy Giant
Healthcare Giant Explores New Business Opportunities with Improved Decision Making