HealthAxis Determinants®


HealthAxis Determinants® enables your organization to take on new business quickly and efficiently by:
  • Reducing staff burden with automated workflows
  • Reducing manual processing
  • Enabling users to handle a large volume of claims
The HealthAxis Determinants® enables partners to reduce unnecessary costs and increase customer satisfaction by:
  • Reducing customer service calls from patients
  • Reducing turnaround time of responding to members
  • Reducing user error with automated workflows
Authorization – used to determine which authorization applies to the claim/line
Benefits – used to determine which benefit applies to the line item
Contract – used to determine which contract can be used for pricing
DOFR – used to determine risk-type
Fee Schedule – used to determine if a fee schedule item applies to the line item
Membership – used to determine how to handle TRC response codes
Pre-Existing – used to determine whether a condition is pre-existing
Rider – used to determine which rider may apply
Sensitive Services – used to determine which services to consider sensitive
Utilization Worklist – used to determine user access/priority within the UM queue
Provider Worklist – used to determine user access/priority within the PR queue
Claim Worklist – used to determine user access/priority within the claims queue
Authorization Worklist – used to determine user access/priority within the authorization queue


As the healthcare landscape becomes more consumer-centric, Payers must rely on innovative technology in order to remain competitive. The HealthAxis Determinants® system provides partners with improved benefit plan implementations, operational efficiencies for lower operating costs and adaptability to a rapidly evolving landscape.
A Determinant is an end-user configurable decision point; and is used in some form or another in every module of the HealthAxis system.
In a claim line item evaluation scenario, HealthAxis Determinants® can be used to do the following:
  • Determine which benefit (if any) applies.
  • Determine whether the line item or the whole claim is a duplicate.
  • Determine which contract will be used for each line item and which fee schedule item it should be priced with.
HealthAxis Determinants
What sets HealthAxis Determinants® apart from any other solution on the market is its revolutionary approach to configuration. Our system enables partners to:
  • Respond to new business opportunities quickly, while reducing costs & improving operational efficiencies.
  • Quickly implement new benefit plans and offerings.
  • Take on new business and automate business lines with the extremely flexible HealthAxis Determinants® rules.