Settlements, remittances, capitation and disputes.
The settlement engine turns approved claims into provider remittances on a predictable cadence - and gives both sides one place to resolve money disputes.
Settlement runs
- Configure cadence: weekly, bi-weekly or monthly.
- A run aggregates all APPROVED claims since the last run.
- One remittance is produced per provider with line-level detail.
- Finance uploads the payment proof - the provider sees it in real time.
A settlement run with each provider's remittance, totals and a payment-proof upload
Screenshot - coming soon
Remittances
| Header | HMO, provider, run identifier, period, total approved, fees, net payable. |
|---|---|
| Lines | One row per claim with member, encounter, approved amount and any adjustments. |
| Payment proof | Bank confirmation uploaded by Finance - visible to the provider instantly. |
| Status | GENERATED → PAID → DISPUTED (if challenged) → RESOLVED. |
A single remittance - header totals, claim-level lines and an attached payment proof
Screenshot - coming soon
Capitation
Separate from claim-based settlements, capitation is a monthly per-enrollee payout to the enrollee's designated primary provider. The capitation module computes it from the enrollee population and the agreed rate per plan tier.
Disputes
- Provider raises a dispute against a specific remittance line.
- The dispute is routed to the HMO's Finance team with the original claim attached.
- Resolution updates the remittance and is fully audit-logged.
Disputes never bypass the audit log. Even a corrected remittance retains the original record and the resolution decision, so reconciliation stays clean.
Reports
- Settlement summary - runs, total paid, top providers.
- Provider performance - submission quality, query rate, denial rate.
- Claims aging - how long claims sit in each state.
Watch a run go out
Settlement run - Finance walkthrough
Schedule, approve, upload proof, resolve a dispute - start to finish.
Walkthrough - coming soon