Payer services for modern health plans
Aethera serves the other side of the claim — helping health plans, TPAs, and risk-bearing entities run accurate, compliant operations across claims adjudication, payment integrity, credentialing, provider data, prior authorization, and appeals.
99.4%
Claims Adjudication Accuracy
6:1
Avg Payment-Integrity ROI
<48 hrs
Provider Data Turnaround
50 States
Regulatory Coverage
WHAT WE DO FOR PAYERS
End-to-End Health Plan Operations
A modular suite you can adopt as a single function or a full back-office partnership — each line built to be accurate, compliant, and measurable.
Claims Operations & Adjudication Support
Configuration-driven claims processing, manual adjudication overflow, COB/subrogation handling, and edit/audit support to keep auto-adjudication rates high and turnaround within regulatory timelines.
Payment Integrity
Pre- and post-pay review, DRG validation, clinical and coding audits, duplicate and overpayment recovery, and fraud-waste-abuse detection that returns multiples of program cost.
Provider Data Management
Roster ingestion, directory accuracy, demographic validation, and continuous provider data maintenance to meet No Surprises Act and CMS directory-accuracy requirements.
Credentialing & CVO
NCQA-aligned primary source verification, initial credentialing and recredentialing, sanctions and exclusion monitoring, and committee-ready files as a full credentials verification organization.
Prior Authorization Administration
Intake, clinical criteria application, medical-necessity review support, and turnaround tracking that keeps utilization management compliant with state and federal timeliness rules.
Appeals & Grievances
End-to-end appeals and grievance case management, regulatory correspondence, and timeliness reporting for commercial, Medicare Advantage, and Medicaid lines of business.
Who We Serve
Our payer services are built for organizations that bear claims, regulatory, and network responsibility — and need an operating partner that treats accuracy and compliance as non-negotiable.
Commercial health plans and regional insurers
Medicare Advantage and D-SNP plans
Medicaid managed care organizations
Third-party administrators (TPAs)
Risk-bearing provider groups, IPAs, and ACOs
Self-funded employers and stop-loss carriers
Why Aethera for Payer Services
Provider-Side DNA
We process millions of provider claims, so we understand both sides of the transaction — and design payer operations that reduce abrasion while protecting the medical-loss ratio.
Compliance-First
HIPAA, SOC 2, NCQA-aligned credentialing, CMS and state-specific timeliness — built into every workflow, with audit-ready documentation by default.
Outcomes, Not Headcount
Engagements are measured on accuracy, recovery, turnaround, and member/provider satisfaction — not hours billed. You buy results.
Built for Regulatory Reality
Every payer engagement runs on HIPAA-compliant, SOC 2-aligned infrastructure with NCQA-aligned credentialing, CMS and state timeliness tracking, and audit-ready documentation — so your compliance team sleeps at night and your regulators stay satisfied.
HIPAA
SOC 2
NCQA-Aligned
CMS & State Timeliness
Let's Talk About Your Plan Operations
Whether you need one function or a full back-office partner, we'll scope a payer-services engagement around your accuracy, recovery, and compliance goals.
Schedule a Capabilities Briefing