Payers | Healthcare Commercial
The Execution Layer for Managed Care
Whether you operate a commercial health plan, Medicare Advantage, Medicaid managed care, or a TPA, Zyter executes the workflows that define your performance. Domain-specific AI agents, policy-aware governance, and continuous learning — built into every step of every workflow.
- 44M+Members Supported
- 45+Enterprise Customers
- 80%Productivity Gains
- #1Everest Group, Care Management 2025
The Managed Care Execution Challenge
Payer operations are under more pressure than at any point in a generation.
The list of demands keeps expanding simultaneously:
Prior authorization volumes are rising
As CMS interoperability mandates compressed determination timelines, standard and urgent requests now have hard regulatory deadlines. Manual review queues are not built for this pace.
Care management programs are accountable for outcomes they cannot always attribute.
High-risk members are enrolled in programs, but most organizations cannot connect specific interventions to specific member-level outcomes — limiting program ROI and budget decisions.
HEDIS and Stars performance drives multi-million dollar quality bonus payments
As well as contract bids and market competitiveness. Most quality programs still operate as end-of-year closure sprints rather than continuous, attribution-tracked workflows.
Claims integrity requires coordination across UM decisions, clinical documentation, and contract terms
Most organizations still manage these across disconnected systems, creating payment accuracy gaps and FWA exposure.
Most technology investments help at one point in this chain. None of it runs coordinated, end to end. Zyter's payer Praxis is the execution layer that changes this.
Payer Praxis
Four execution workflows. One connected system.
Zyter's payer Praxis covers the full managed care stack — from the moment a prior auth request arrives to the workflows that close quality gaps, process claims, and manage your provider network.
Real-time prior authorization — from intake to determination.
UM Praxis automates the full prior authorization lifecycle with AI agents purpose-built for each step. Requests arrive through every channel. Clinical documentation is extracted and assembled automatically. Cases are scored, routed, and decided — with full decision lineage at every point.
Capabilities:
- Multi-channel request intake: EDI 278, FHIR PAS, provider portal, fax, EHR direct
- Eligibility and benefit validation at intake
- AI-powered clinical documentation review and extraction
- Guideline and policy evaluation: MCG, InterQual, custom plan policies
- Intelligent triage and routing across intake, nurse, and MD workflows
- Clinical review support and AI-assisted determination
- Automated determination and notification (approvals, denials, pend)
- Compliance and TAT management with regulatory audit readiness
- Downstream integration: CM referral trigger, claims alignment, network steerage
- Appeals and grievances lifecycle (intake through external review)
From risk identification to care plan execution — end to end.
CM Praxis moves clinical teams from reactive outreach to intelligent, next-best-action execution. Every member is continuously stratified across clinical, social, behavioral, and financial risk dimensions. The right interventions surface at the right moment. Care programs execute within a unified workspace built for the way care managers actually work.
Capabilities:
- Member intake and multi-dimensional risk stratification (clinical, SDoH, behavioral, financial)
- Comprehensive assessment library: HRA, PHQ-9, SDoH screeners, LTSS, condition-specific
- ADT event monitoring, readmission detection, and medication non-adherence signals
- AI-generated care plans with SMART goal support and barrier identification
- Next-Best-Action ranking with explainability — separating clinical judgment from automatable tasks
- Care gap identification: HEDIS, Stars, preventive, chronic, behavioral, adherence
- 18+ evidence-based care programs: Transitions, CHF, CKD, COPD, OB, SUD, LTSS, and more
- Omnichannel member engagement: SMS, voice, email, portal, mobile app, conversational AI
- Unified care manager workspace: task queue, care plan editor, caseload view
- Quality performance tracking and HEDIS outcome attribution to CM interventions
AI-native claims execution — from intake to integrity.
Claims Praxis applies AI agents across the full claims lifecycle — from the moment a claim arrives to the point where payment accuracy is confirmed and insights feed back into UM policy and provider strategy. Every step is traceable. Every exception is surfaced. Every pattern is learned.
Capabilities:
- Centralized claim intake across EDI, portal, fax, and documents
- AI document processing and data extraction from unstructured inputs
- Eligibility, benefits, and provider validation
- Duplicate detection and coordination of benefits (COB) analysis
- Intake error identification and denial risk prediction before processing
- PA-to-claims matching and authorized vs. billed service reconciliation
- AI-powered adjudication triage: straight-through vs. complex routing
- Dynamic rule orchestration: payer policies, contracts, and benefit rules applied together
- Explainability and audit trail at every determination point
- FWA detection and anomaly identification
- Closed-loop insights back to UM policy and provider performance
Accurate provider data, everywhere your operations depend on it.
Provider intelligence is the operational foundation for UM, claims, and network performance. Zyter's Provider Data Praxis manages the full provider data lifecycle — from credentialing and directory accuracy to the real-time analytics that inform network strategy.
Capabilities:
- Multi-source provider data ingestion, normalization, and deduplication
- Credential aggregation, license verification, and ongoing revalidation
- Provider directory management and No Surprises Act / CMS compliance
- Unified Provider 360 profile across all systems
- Affiliation and relationship mapping
- Provider performance and utilization analytics
- Data API enablement for downstream UM, claims, and CM systems
What Powers It All
Every payer workflow runs on the same governed execution platform.
Zyter's payer Praxis is built on TruCare — the enterprise digital core that connects your claims platform, EHR integrations, pharmacy data, and member data into a coordinated execution environment. Every workflow is governed by Zyter Symphony, the AI orchestration control plane that routes work, enforces policy-aware execution, and maintains full decision lineage across every step.
Your PHI stays in your environment. The system gets smarter with every case it runs.
TruCare PHM
Enterprise digital core for end-to-end managed care operations
Zyter Symphony
AI orchestration control plane: 42 governed meta-agents, fully auditable
Decision Lineage
Every determination traceable. Every outcome measured.
From Deployment to Value
Production-scale execution in weeks, not quarters.
SmartStart brings preconfigured payer workflows, 40+ prebuilt agents, and FHIR/HL7 connectivity into your environment — compressing the time from discovery to production-scale AI execution. RECODE ensures the workflows being automated are worth automating.
SmartStart
Preconfigured UM, CM, and claims workflows ready for your environment on day one.
RECODE
Workflow redesign methodology to ensure AI executes the right process, not just the existing one
Zyter System Graph
The production-ready execution environment connecting platform layers, systems, and decision actors