High standards. Deep experience.

With nearly 80 years of experience and billions of claims processed, we provide efficient, secure and compliant claims administration. You’ll benefit from our trusted technology, knowledgeable team and unwavering commitment to security—ensuring your claims are handled smoothly, quickly and accurately.

Our capabilities are enhanced by our integration with Defense Enrollment and Eligibility Reporting System (DEERS), Veterans Affairs (VA), Centers for Medicare and Medicaid (CMS) and compliance with the highest possible security standards, including FISMA High.

Core Competencies

• Scale: We process up to 7.8 million claims per month, with 99.9% of them completed within 30 days and a consistent accuracy rate exceeding 99%. This efficiency supports over 7 million Medicare beneficiaries and 9 million military personnel and their families, contributing to the more than $62 billion in payments we handle annually.
• Integration: We are seamlessly integrated with Defense Manpower Data Center (DMDC), Centers for Medicare and Medicaid (CMS) systems, and DEERS for real-time verification and data sharing. Application Programming Interfaces (APIs) allow easy connection with external systems.
• Compliance and security: We are fully compliant with HIPAA X12 and NIST standards. Our FISMA High rating ensures the highest level of security in claims processing.
• Automation-driven efficiency: Our pioneering use of automation makes us industry leaders in audit and reimbursement (A&R) and consistently enables claims auto-adjudication rates above 98%, while maintaining essential human oversight for accuracy.
• Expertise: Our domain specialists are leaders in delivering innovative, customer-focused solutions through Agile methodologies.
  • We pioneered the EDS integration with DMDC, enabling smoother data sharing and enhanced system performance.
  • With the VA, we developed a highly customized invoicing system that addresses their unique needs.
  • Our team has also worked on advanced CMS compliance solutions, continually evolving our offerings to not just meet, but exceed the ever-changing regulatory landscape.
• Data analytics: Our team of credentialed data scientists, healthcare informatics analysts and statisticians perform comprehensive data analytics to support informed decision-making.
  • We provide a range of services, including predictive analytics, claims data analysis, quality of care assessments, population health management, cost analysis, utilization management, and customer satisfaction metrics.
  • We leverage the CMS Integrated Data Repository (IDR) for specific insights related to our MAC contracts, and our core data analytics capabilities extend across various business lines, delivering actionable insights to meet diverse needs.

Enjoy a streamlined health plan experience with our secure, integrated billing and enrollment systems. Our advanced rules engine ensures that enrollments and premium payments are processed quickly and accurately, so you can avoid errors and delays. This means less hassle for you and more confidence in your health plan, improving your overall experience and saving you time.

For TRICARE participants, our full DEERS integration further enhances this capability, delivering precise and efficient processing tailored specifically to TRICARE's unique needs.

Core Competencies

• Integration: Our expertise in integrating with government systems ensures secure, seamless data flow and minimizes processing errors. We have extensive experience working with systems such as DEERS and Beneficiary Web Enrollment (BWE), as well as integration projects with CMS and the VA.
• Payment flexibility: We support multiple payment options, including credit card, ACH, and allotment, accommodate a variety of beneficiary needs.
• Efficiency: Our system processes up to 540,000 transactions per hour, with the latest PRV Gold on the TRICARE side allowing us to handle nearly 9,000 transactions per minute. In just five hours, we can successfully process 2,677,819 transactions.
• Security and compliance: Our PCI-compliant payment services and HIPAA X12 standards ensure the highest security across all billing and enrollment processes.
• AI for process automation: We’ve innovated with AI to improve accuracy in transaction processing and report generation.
• Provider management: We are industry leaders in managing both network and non-network provider data, handling provider enrollment, outreach, education, and delivering dedicated support.
  • We employ proven processes and cutting-edge technology to streamline provider enrollment, minimizing provider burden and ensuring efficient, seamless operations.
  • Our best-practice models set the standard for keeping enrollment on track, particularly in managing complex enrollment and verification processes for government programs.

Our Data Logistics division is your behind-the-scenes powerhouse. We handle the full spectrum of Business Process Outsourcing (BPO)—securely and compliantly. From scanning incoming mail and processing paper claims to managing outgoing correspondence, we’ll handle every data detail. The result? Less risk, greater efficiency and more time for you to focus on what matters most: running your organization.

Core Competencies

• Scalability and security: We have a secure location setup with long-term storage and reliable backup capabilities for sensitive data.
• Technology-driven efficiency: We use OCR and automated classification to process documents quickly and accurately.
• Compliance: We maintain HIPAA and NIST compliance to safeguard data throughout all stages of print and mail handling.
• AI-powered processing: We’ve integrated AI to optimize document scanning, categorization, and error detection for faster turnaround times.

Whether you're in the public or private sector, you can count on us for secure, seamless data exchange that scales with your needs. Our systems are built for compliance, designed for flexibility and backed by robust security—so your data moves smoothly, integrates easily and always meets national standards.

Core Competencies

• Data transfers: Our self-service EDI portals provide fast, ANSI-standard, secure file transfer, safeguarding sensitive information.
• Integration: We have full integration with CMS, DHA, and DEERS systems, enabling real-time access and seamless data sharing across platforms.
• Security standards: We operate under FISMA High standards, ensuring a high level of security for data transfers.
• AI-enhanced data flow: We use AI to help streamline data connections and fosters timely processing of transactions.
• Data analytics: Our in-depth data analysis offers enhanced insights and decision-making.

Feel confident knowing your claims are accurate, compliant and protected. With powerful fraud detection and rock-solid security protocols, we help shield your organization from fraud, waste and abuse. This means fewer costly mistakes, smoother processing and peace of mind at every step.

Core Competencies

• Fraud detection and prevention: Our AI-driven systems monitor claims for anomalies, identifying potential fraud early in the process.
• Regulatory compliance: Our strict adherence to FISMA High standards ensures all claims are processed securely and reported properly.
• Investigation and reporting: Our dedicated teams conduct internal investigations and collaborate with law enforcement to ensure accountability for fraudulent claims.
• Provider audits: Our skilled audit team ensures accuracy in provider cost reports and claims processing, helping detect fraudulent activities.

At WPS, we’re known for our friendly, compassionate and knowledgeable support team, who provide answers and solve issues lightning fast. Our goal is to create an elevated customer service experience—every time. We’re here to advocate for you, always.

Core Competencies

• Security-first approach: All customer interactions are handled with FISMA High-level security, ensuring data protection.
• Friendly, local customer service: Based right here in Wisconsin..
• Technology-enabled support: Our 24/7 self-service tools ease the burden on beneficiaries and providers, allowing them to access data securely at any time.
• AI-driven support: Our AI tools help streamline customer inquiries and automate common tasks, improving response times without compromising security or our personal touch.