Health Plan Solutions

Advanced NLP-enabled Risk Adjustment Solution for Medicare Advantage, ACA Commercial and Medicare ACO Markets
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Automate Claims Validation for Increased Coding Accuracy and Completeness

In today’s complex and heavily regulated environment, health plans must be prepared for increased scrutiny of their HCC and HHS submissions to CMS. Manually intensive, retrospective chart reviews are error-prone and costly—particularly for payer organizations that are relying on a third-party for second and third pass reviews.Claims InSight by Talix automates the code validation process so that health plans can gain more control of their in-house risk adjustment initiatives, improve coder productivity and ensure accurate code submissions that adhere to ever-changing regulatory coding guidelines.

Powered by our Talix Platform, Claims InSight combines the power of machine learning with purpose-built natural language processing (NLP) technology, a sophisticated clinical rules engine and an extensive clinical taxonomy to quickly link all submitted HCC and HHS codes to available clinical encounters and charts to uncover codes with documentation gaps or no supporting evidence in member data. It then enables the user to flag the code for deletion or update. Coders, as a result, can efficiently review and validate more submitted HCC and HHS codes with improved accuracy and completeness.

Automated Risk Stratification

Detect and prioritize members with the most missed codes and documentation gaps for improved visibility and ROI

Comprehensive Coding Workflow

Increase productivity and accuracy with support for claims validation and code reconciliation in a single, intuitive and powerful workspace

Analytics and Reporting

Gain real-time, actionable insight on coding performance to better manage the financial impact from risk adjustment, boost RADV and compliance confidence and assist with provider education initiatives

Automated Claim Validation

Streamline the reconciliation process and ensure all claimed codes have supporting documentation with evidence from member data

Automated Risk Adjustment Coding for Improved Efficiency and Productivity

The Coding InSight workflow application combines our proprietary, purpose built NLP, machine learning and an extensive health taxonomy to streamline the manually intensive retrospective chart review process. Coding InSight quickly uncovers missed codes and documentation gaps in member data so coders can process higher chart volumes with increased accuracy and efficiency, for improved plan revenues, higher audit confidence and reduced administrative costs.

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Robust Features TransformYour Coding Workflow into a Powerful Tool for Risk Adjustment Success

Analytics and Reporting

Coding InSight’s comprehensive suite of dashboards delivers real time, actionable data that enables administrators to track coder productivity and financial impact from risk adjustment. Coding InSight also tracks provider coding patterns for improved provider engagement and CDI initiatives.

Automated Suspect Identification

Coding InSight is fully automated so coders can identify
missed codes and documentation gaps faster and with a higher level of accuracy. We take away the need to manually comb through large volumes of clinical data, which is both time-consuming and error-prone.

Unified Coder Workspace

Coders view all relevant clinical and financial member data in a single intuitive, yet powerful workspace to quickly and accurately reconcile codes

Multi-Factor Auditing Capabilities

Coding InSight streamlines the reconciliation process by making code recommendations based on evidence found within the member data. Coders gain a clear line of sight between claimed codes and supporting documentation in case of an audit.

Gain more control of your risk adjustment processes. Increase efficiency. Lower costs. Improve revenue.


Coder Productivity Increase



“Accurate and complete diagnostic coding provides a comprehensive disease burden profile of our members. As our member population grows, we needed an advanced diagnosis coding solution to help improve our productivity so we can support increasing workloads while still maintaining our high quality standards. Coding InSight helps us identify un-coded or mis-coded opportunities in a more effective and efficient way.”
 Karena Weikel, ASA, Vice President of Risk and Revenue Management, Geisinger Health Plan
Creativity redefined. These guys offer a unique approach to every aspect
of design and the result is simply stunning.
Creativity redefined. These guys offer a unique approach to every aspect
of design and the result is simply stunning.

Second Level Chart Review

Results—Talix Always Delivers
  • ROI: We have delivered 8X-12X ROI
  • New HCC Codes: Tens of thousands of new codes accepted
  • Accuracy: Always over 95%
  • Productivity: 2X-3X faster than other partners
  • Speed to Impact: Processed 90K charts in 6 weeks, surpassing all customer success measures

Reporting and Analytics Module

Reporting Module enhances Talix’s Risk Adjustment Application Suite with Powerful Persona-Based Analytics

Talix Platform

The Core Technology that Powers Talix

We built the Talix platform with one goal in mind: to provide powerful, high quality, analytics-driven solutions that enable risk-bearing organizations to gain greater insights and succeed in the age of value based care

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SaaS Application Framework
(Cohort Designer, Reporting/ Analytics Framework, Administrative Interfaces, Data Connectors, OCR)

Clinical Taxonomy


Clinical Rules

Machine Learning