Claims Repricing
Turn claim files into quantified repricing opportunities.
Reprice eligible commercial claims. Compare payer amounts and inspect each calculation.
Repricing differences identify review candidates, not confirmed underpayments.
Find the largest repricing differences across your claims.
Missing remits, denials, partial payments, and unmatched rates each need a different next step.
Use calculated repricing differences and available explanations to prioritize claims for review.
HOW CLAIM REPRICING WORKS
Automatically reprice eligible claims against negotiated rates.
Add your claim and remit files.
Group 837 claims and 835 remits in a project. PayerPrice checks payer eligibility.
Compare repriced and payer-reported amounts.
Compare both repriced amounts with the payer baseline. Inspect matched rates and service-line calculations.
Rank claims by repricing opportunity.
Sort by repricing opportunity or service date. Filter by payer and status to focus your review.
FROM RESULT TO REVIEW
Inspect the calculation behind each repriced claim.
Inspect both repriced amounts, the baseline, service lines, and available explanations.
Record a review status or note, or export the analysis for your team to investigate further.
Schedule a repricing walkthroughTrace each result to its rates and adjustments.
Inspect the matched rates and calculation details to understand the result and what still needs review.
Read the repricing FAQs →Compare conservative and optimistic amounts
See conservative and optimistic results and review the adjustments that produce the difference between them.
See which payer amount sets the baseline
Check payer allowed, payer paid, and patient responsibility to understand the comparison baseline.
Review the evidence behind likely explanations
Inspect evidence for a conservative repricing difference before deciding whether to investigate further.
Check claim eligibility and repricing requirements.
Check eligibility, calculation definitions, and file requirements before starting your project.
Schedule a repricing walkthrough →What is a repriced amount?
An amount calculated from matched negotiated rates, claim service lines, and repricing adjustments.
Open the claim detail to inspect the inputs and calculation.
Why are there optimistic and conservative amounts?
They reflect different adjustment scenarios applied to the matched rates.
Review the adjustment details to see why the amounts differ for a claim.
What does PayerPrice use as the comparison baseline?
The baseline is the lower available amount: payer allowed, or payer paid plus patient responsibility.
Opportunity is the repriced amount minus that baseline, with a minimum of zero.
Missing comparison data can prevent calculation.
Which claims are eligible for automated repricing?
Claims need an eligible commercial primary payer. Other or missing primary payers are excluded.
Calculation also requires usable claim details and matching rate data.
What happens when no matching price is found?
The result shows no matching rate. Check the claim inputs and rate coverage before retrying.
A missing match does not establish whether the payer's payment was correct.
Can I inspect the line-level calculation?
Yes. Open a claim to review service-line inputs, matched rates, adjustments, and available explanations.
Add a note or review status as your team investigates.
Does a repricing opportunity prove an underpayment?
No. It identifies a calculated difference for review.
Consider the contract, claim details, and payer adjustments before deciding what action to take.
What do we need before uploading claim files?
Your account needs Claims Repricing enabled. Your organization must accept a business associate agreement (BAA).
The workflow uses 837 claim and 835 remit files. Schedule a walkthrough to confirm access and file requirements.
Walk through claim repricing with our team.
Walk through the file requirements, repricing results, and claim detail before setting up your first project.