Your engine behind healthcare claims and payments.
Payor Systems runs manufacturer-funded patient support through real medical claims, Rx data, and provider reimbursement, built for medical-benefit drugs that don't fit pharmacy coupon models.
Medical-benefit drugs break traditional support models.
Fragmented benefits
Medical and pharmacy run on different rails. Programs spanning both are hard to execute consistently across thousands of patients and provider sites.
Provider friction
Physician offices already manage benefit checks, forms, claims, and reimbursement with limited staff. Manual hub programs add work that delays therapy and creates abandonment risk.
Manufacturer blind spots
Brands rarely see where patients stall: eligibility, claim status, deductibles, denials, or reimbursement. Program data is fragmented across vendors.
Designed around how healthcare actually gets paid.
Manufacturers
Brand-specific program rules, eligibility logic, funding controls, and full visibility into where every patient sits in the program, from benefit check to provider payment.
Physician offices
Submit claims through the same EHR and clearinghouse workflow they already use. No new portals, no manual claim forms, no separate billing process.
Patients
Affordability applied at the point of care, with clear explanation of support and remaining responsibility, not a coupon to remember at the pharmacy.
Payers and PBMs
Coordinated claim logic, government program exclusions, and benefit signals integrated into existing operations without disrupting normal payer workflows.
One workflow, five connected parties.
Swipe diagram to explore →
Benefit and program check
Eligibility, brand rules, government exclusions, plan signals.
Provider submits the claim
Standard EHR/clearinghouse claim flow, no special process required.
Rules-based adjudication
Coverage, cost share, limits, and manufacturer program rules applied.
Payment and remittance
835/EOP, EFT, check, NACHA, and reconciliation files generated.
Visibility and insights
Real-time claims, payment, access barriers, and utilization back to the brand.
Benefit and program check
Eligibility, brand rules, government exclusions, plan signals.
Provider submits the claim
Standard EHR/clearinghouse claim flow, no special process required.
Rules-based adjudication
Coverage, cost share, limits, and manufacturer program rules applied.
Payment and remittance
835/EOP, EFT, check, NACHA, and reconciliation files generated.
Visibility and insights
Real-time claims, payment, access barriers, and utilization back to the brand.
Providers don't learn a new process. The program fits the one they already use every day.
Medical claim infrastructure for patient access programs.
Manufacturer program design
Brand rules, funding logic, service and drug coverage definitions, patient eligibility criteria, controls and guardrails.
Integrated benefit intelligence
Rx data, medical eligibility, payer and PBM signals, and government program exclusion rules in one decision layer.
Medical claim administration
837 intake, provider validation, claim edits, adjudication, secondary/COB logic, and exception handling.
Payment operations
Provider reimbursement, 835 ERA/EOP, EOB generation, EFT, check, NACHA, and reconciliation.
Reporting and governance
Claims dashboards, payment analytics, audit trails, utilization data, and access barrier insights.
One platform. One operating model. Multiple brands, programs, rules, and routes.
From claim intake to payment visibility.
Every claim moves through the same four stages, with a full audit trail at each step.
Claim intake
Automated receipt, parsing, and validation of X12.837 claim files, extracting claim detail, program codes, and member and provider information for processing.
Adjudication
A configurable rules engine validates provider eligibility, enrolls members, checks coverage and duplicates, and calculates drug price, deductibles, and member cost share after the program is applied.
Payment processing
Claims are bundled by provider, X12.835 remittance advice and NACHA EFT files are generated, and funds are disbursed with payment notifications and full audit trails.
Claims and payment visibility
Claim management dashboards, claim detail, member-facing EOBs, and payment run logs, with drill-down access to every payment and claim.
Built as infrastructure, not a hub workaround.
Typical hub or coupon vendor
- Manual support steps and patient enrollment forms
- Pharmacy-centric coupon logic, not medical claim logic
- Limited control over medical-benefit claim adjudication
- Partial visibility, usually only after the service is delivered
Payor Systems
- Medical claim and payment infrastructure designed for brand programs
- Medical and Rx benefit intelligence in a single workflow
- Configurable, brand-specific adjudication and program rules
- Closed-loop visibility from benefit check through provider payment
Other vendors assist around the edges. Payor Systems is the operating layer.
Map your program to Payor Systems.
We'll walk through your brand rules, eligibility logic, claim route, provider payment model, Rx data integration, and a phased launch plan. Designed for medical-benefit drugs where coupon programs don't fit.