Available to VE Suite Customers Only
Automate Your Claims Systems
✅ Plans, MSOs, and PACE Organizations
✅ Real-Time Claims Review
✅ Epic, EZ-Cap, Plexis, and QuickCap
✅ Auto-Deny or Auto-Approve
✅ Customizable to Your Business
VEWS is your Real-Time Claims Automation Solution
Built as a secondary add-on to the Virtual Examiner® Suite, VEWS brings VE’s validated determinations directly into your live claims environment—allowing payers to enforce clean, defensible decisions at the point of submission. Rather than replacing your adjudication system or retrospective audit process, VEWS works alongside them to reduce manual review, eliminate low-value claim handling, and enable automation where rules are clear. The result is a claims workflow that moves faster, touches fewer hands, and applies consistent logic before errors ever reach your team.
Real-time Determinations
Instant Claims going back 5 days
Save time and eliminate surface-level errors that clog your workflows. VEWS performs real-time audits on every incoming claim, going back five (5) days to catch hard edits instantly—terminated codes, wrong gender, wrong POS, invalid NDC/HCPCS combinations, conflicting diagnoses, and more. Instead of your team researching these issues manually, VEWS identifies the error, returns the edit reason, and provides a suggested action within seconds.
What types of CCI edits does VEWS catch?
VEWS evaluates claim-level Correct Coding Initiative (CCI) logic in real time, identifying procedure-to-procedure conflicts, mutually exclusive services, invalid modifier usage, and CMS-defined bundling violations as claims enter your system. Unlike traditional scrubbers that only review individual claim lines, VEWS analyzes claim context and recent claim history to surface conflicts that span multiple services or encounters. Each flagged line is returned with the exact CCI edit, CMS reference, and a clear explanation of why the service should be denied or reduced—making the determination immediately actionable.
You'll never have to review these types of claims?
VEWS is designed to remove your team from repetitive, low-value claim handling. Claims that fail objective validation rules—CCI conflicts, terminated or invalid codes, wrong gender, incorrect place of service, or basic CMS compliance errors—can be automatically flagged with a recommended denial or reduction before manual review ever occurs. When claims hit Epic, EZ-CAP, Plexis, or QuickCap, the system receives the determination reason and suggested action instantly, allowing clean claims to flow through while reserving human review for true clinical or policy-driven decisions.
VEWS Real-Time Integrations
How does VEWS populate in our adjudication software?
VEWS runs a real-time claim validation the moment a claim is submitted or received, evaluating it against VE logic, CMS/CCI rules, and payer-defined validations within a rolling 3–5 day window. The determination is returned instantly into your existing claims platform—Epic, EZ-CAP, Plexis, or QuickCap—without requiring users to leave their workflow. VEWS does not replace your adjudication system or scrubbing tools; it enhances them by inserting defensible, rules-based decisions exactly where claims teams already work.
How long does VEWS take to get live?
Most VEWS implementations go live in approximately 30 days, depending on internal IT availability and claims platform readiness. VEWS is deployed as a real-time integration—there is no downtime, no system replacement, and no disruption to existing workflows. Your team continues working inside the same claims software while VEWS operates in the background delivering instant determinations.
How I add automations to VEWS suggested actions?
VEWS provides the decision logic, while your claims system or automation vendor executes the action. Once VEWS returns a suggested determination, your team can configure automation rules to immediately deny, pend, route, or pay claims—without human intervention.
What will IT and Automation Companies need to do?
IT teams and automation partners do not need to rebuild or replace existing claims systems to use VEWS. Their role is limited to integrating the VEWS API, mapping inbound claim fields and outbound determination values, and configuring automation rules based on VEWS results. This includes routing VEWS denial reasons, edit codes, and suggested actions into existing workflows to support auto-denials, auto-pends, escalations, or approvals. VEWS supplies the compliant decision logic; your automation stack executes the action. Once configured and validated with test claims, VEWS operates continuously with no ongoing IT lift, no additional screens, and no disruption to existing claims operations.
Possible Claims Automations
Immediate Payment or Denials
VEWS evaluates each incoming claim in real time and returns a structured determination—including the specific denial reason, edit code, and recommended action. Automation or adjudication systems then use that response to immediately file the denial with the correct reason code and messaging, without analyst involvement. If no VEWS trigger is present, the claim is routed to Virtual Examiner® for full historical review across the prior three (3) years. For emergency claims, pay-through logic can be applied when appropriate, unless VEWS flags an outlier payment amount that exceeds payer-defined thresholds, in which case the claim is held or routed for further review.
Immediate Denial for Non-Payable Claims
VEWS identifies claims that fail basic CMS, AMA, or payer-defined validation rules and returns a clear denial recommendation with the applicable edit logic. These include invalid codes, non-covered services, demographic mismatches, and policy conflicts that are not eligible for payment under any circumstance. Automation systems can immediately apply the denial using VEWS-provided reason codes, eliminating unnecessary analyst review while ensuring determinations remain defensible.
Pay-through Logic for Eligible Claims
When a claim meets all required coding, policy, and validation criteria—and no VEWS edits are triggered—it can proceed directly through the adjudication workflow without manual interruption. VEWS does not override payer contracts or CMS payment rules; it simply confirms that no compliance, coverage, or coding violations are present at intake. This allows clean claims to move faster while preserving downstream audit protections through Virtual Examiner®.
Escalation for High-Risk or Outlier Claims
Claims that meet basic requirements but present elevated financial or compliance risk—such as unusually high allowed amounts, atypical utilization patterns, or payer-defined dollar thresholds—can be flagged for escalation rather than automated payment. VEWS returns the risk indicator and supporting rationale so automation systems can route the claim to Virtual Examiner® or clinical review. This ensures emergency or time-sensitive claims are handled appropriately without exposing the plan to avoidable overpayments.
Working with Automation Companies
Who can help with the Automation?
When your team is ready to automate real-time decisions, routing, and approvals across claims and authorizations, VEWS works hand-in-hand with your existing automation partners. Whether your organization uses RPA teams, workflow engines, custom middleware, or enterprise integration vendors, VEWS plugs directly into their process—ensuring determinations, clinical logic, and compliance reasoning flow cleanly from VEWS into your automation stack without manual steps. This partnership eliminates human error, reduces backlog, and ensures every automated approval or denial follows CMS, Medicaid, and payer-specific guidelines.
Our Partners
We work directly with your automation vendors, internal IT teams, and external integration firms to ensure VEWS determinations populate exactly where they’re needed. Our most common partners include HCIM and Key Software.
Match authorizations with contracts
VEWS ensures every authorization is checked against the correct contract terms, reimbursement rules, and plan requirements before approval. Your automation vendor can use VEWS’ real-time logic to auto-route auths that meet contract criteria and flag high-risk, non-compliant, or out-of-scope requests for manual review. This reduces downstream denials and prevents the “auth it, pay it” problem.
Ensure auth systems are compliant
Automation only works if the source logic is correct. VEWS validates every authorization and claim against CMS, AMA, CCI edits, Medicaid rules, and payer-specific policies in real time. Your automation team uses VEWS’ reasoning text and determination codes to ensure your authorization engine is always compliant — even when quarterly code updates or rule changes occur.
Client Results & FREE Audits
VEWS is an Add-on to VE
Before launching VEWS, we provide a free full 3-year claims audit to show what VE would have found and what VEWS will automate going forward. This analysis uncovers missed denials, reductions, improper payments, and high-risk patterns your team could not have caught manually. These findings become your roadmap: how VEWS will automate claims, streamline authorizations, and prevent future overspend the moment your system goes live.
What do we need to start a FREE audit
You’ll sign a Mutual NDA and BAA, then securely send three years of claims data. We analyze the data for 3–5 weeks and return a full findings presentation including dollar savings, compliance exposure, duplicate trends, and ROI projections. This audit is completely free and requires no commitment.
How our clients getting a 90-Day positive ROI?
Most organizations see ROI in under 90 days because VE immediately identifies duplicate payments, incorrect codes, global conflicts, and unbundled procedures. These savings occur before your team even finishes implementation. VE’s combination of automation and accuracy is the reason payers see measurable results faster than any other claims auditing software.
How does implementation and training work?
Installation is completed in 1–2 weeks on your secure intranet. We then conduct a 5-day onsite training with your Claims, SIU, and Medical Management teams. Week One you are fully operational, auditing live claims, and generating immediate savings. No lengthy onboarding, no outsourcing, no delays.
How to Get Started with VE and VEWS
1
VE and VEWS Consult
Have a 45-minute discovery call with our CSO to discuss your needs, explore how VEWS automates claims and authorizations in real time, and ensure your systems (Epic, EZ-Cap, Plexis, QuickCap, etc.) are ready for integration. If the fit is right, we’ll proceed to the VE audit and VEWS automation planning.
2
3-Year Claims Audit Analysis
Once the NDA and BAA are signed, submit three years of claims data. In 3–5 weeks, we will conduct VE’s episode-of-care audit to identify missed denials, reductions, improper authorizations, and automation opportunities. These findings will outline what VEWS will automate, the savings achieved, and real-time determinations.
3
On-Site Audit Reveal
We meet with your decision-makers to present the VE audit, projected VEWS ROI, and an automation plan for claims, authorizations, routing, and integrations. We discuss options for real-time determinations, automated denials, and provider insights. After approval, we finalize the contract and begin implementation.
4
Implementation and Go-Live
After signing the agreement, we start VEWS installation and system integration with Epic, EZ-Cap, Plexis, or QuickCap. We hold configuration meetings with your automation company, map decision logic, and conduct testing and validation. Your Claims, Medical Management, and IT teams receive training as automated processes are gradually activated. Once testing is validated, VEWS goes live—offering real-time auditing, compliance, and automation from Day One.
