Naviquis

What Naviquis does

Naviquis is a U.S.-based healthcare payment integrity company founded in 2022 and operationally launched in September 2023 as a subsidiary of HealthWare Systems, headquartered in Elgin, Illinois with a secondary presence in Kansas City, Missouri. The company targets healthcare payers and Third-Party Administrators (TPAs) with a post-adjudication, pre-pay solution designed to detect and prevent fraud, waste, and abuse (FWA) in medical and dental claims before payment is issued. Its core products are the Naviquis Payment Integrity Solution and the Provider Relationship Management System (PRMS), with Credentialing Pro offered as a PRMS module for automated provider verification and monitoring.

The platform combines artificial intelligence, machine learning, and a proprietary methodology called Mobilized Computable Biomedical Knowledge (MCBK) that converts clinical narratives, protocols, and best practices into machine-executable code, enabling multi-vectored review of claims across clinical knowledge, informatics, forensics, and IT dimensions. Naviquis claims outcomes including an average of 5% savings on claims analyzed, a 10:1 client ROI, 95%+ accuracy, 2-5% additional savings above incumbent solutions, and 3-6% of claimed amounts flagged for anomalies. The company also applies natural language processing to clinical notes and AI-based image analysis (e.g., X-ray review) for dental claim integrity.

Naviquis generates revenue on a subscription/recurring basis through its payment integrity and PRMS offerings, with pricing provided on a quote basis to enterprise buyers. Distribution is sales-led, with direct enterprise engagement initiated through a 'Request a Demo' CTA on the company website. The company holds SOC 2 Type I (July 2023) and SOC 2 Type 2 (November 2023) certifications at the parent-company level, supports a content marketing program including the Naviquis Navigator newsletter, and operates with 11-50 employees.

Name

Naviquis

Legal name

Naviquis

Website

https://naviquis.com

Company type

Private

Founded year

2022

Operating status

Operating

Headcount range

11–50 employees

Short description

Naviquis is a U.S. healthcare payment integrity subsidiary of HealthWare Systems that uses AI, ML, and proprietary MCBK technology to detect and prevent fraud, waste, and abuse in medical and dental claims for healthcare payers and Third-Party Administrators.

Ownership category

akta.pro rank

Product category

Healthcare Payment Integrity Software

NAICS

Financial Transactions Processing, Reserve, and Clearinghouse Activities (522320)

SIC

Hospital & Medical Service Plans (6324)

akta.pro primary industry

Payer-Provider Data Exchange (X12, prior auth, claims/clinical attachment) (HLACABAK)

akta.pro secondary industry

Accounts Receivable (A/R) & Collections Management (HLACACAJ)

Keywords

• Payment integrity solutions
• Healthcare fraud detection
• Claims analysis software
• Provider relationship management
• FWA prevention platform

Headquarters

HQ city

Elgin

HQ country

United States

HQ region

North America

Offices2 records

Markets served

GTM type

B2B

Offering type

Software

Cost components

Personnel, Technology or R&D, Marketing or Sales, Operations, Infrastructure

Revenue model

1. Payment Integrity Solution: Naviquis generates revenue through its payment integrity solution that detects and prevents healthcare fraud, waste, and abuse. The company offers a post-adjudication, pre-pay integrity solution that reduces overall costs and provides immediate ROI while increasing client savings, TPA revenues, and provider satisfaction. The company reports an average of 5% savings found by Naviquis with a 10 to 1 ROI.
2. Provider Relationship Management System (PRMS): Revenue stream from the PRMS platform which provides communication, alerts, credentialing support, and educational notes to providers. The platform is part of the comprehensive payment integrity solution offering.

Go-to-market motion2 records

Distribution channels1 record

Marketing channels7 records

Core offering

Naviquis provides a healthcare payment integrity platform that combines AI, Machine Learning, and Mobilized Computable Biomedical Knowledge (MCBK) to detect and prevent fraud, waste, and abuse (FWA) in medical and dental claims on a post-adjudication, pre-pay basis. The platform includes the Naviquis Payment Integrity Solution for real-time claims analysis and the Provider Relationship Management System (PRMS) for automated provider communication, education, and credentialing monitoring. Naviquis sells primarily to healthcare payers and Third-Party Administrators (TPAs) as an enterprise B2B subscription offering.

Product overview

Naviquis offers a unified healthcare payment integrity platform composed of two primary products: the Naviquis Payment Integrity Solution for FWA detection/prevention, and the Provider Relationship Management System (PRMS) for provider communication and credentialing. Credentialing Pro is a module within PRMS that automates provider verification. The platform combines AI, ML, and Mobilized Computable Biomedical Knowledge (MCBK) to detect and prevent fraud, waste, and abuse in medical and dental claims before payment.

Differentiator

Problem solved

Functional benefit

Products and services

• Naviquis Payment Integrity Solution A real-time, fully automatic, post-adjudication, pre-pay payment integrity solution that detects and prevents healthcare fraud, waste, and abuse (FWA) in medical and dental claims before payment. Sold to healthcare payers and Third-Party Administrators (TPAs) seeking automated claims review with precision edits, reporting/analysis, and communication features.
• Provider Relationship Management System (PRMS) A provider relationship management platform that provides secure, automated, real-time communication with providers, an education hub for FWA awareness, and credentialing and licensing monitoring. Designed for healthcare payers and TPAs to reduce provider abrasion and improve network relations.

Quantifiable outcome

• 5% average savings found by Naviquis on claims analyzed
• +4 more outcomes

Segments3 records

Ideal customer profiles2 records

Technology focussed Yes

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

AI capability8 records

Feature5 records

Partnerships

Two partnerships are on record, tiered core and minor.

• HealthWare SystemscoreOthers · 17 July 2023HealthWare Systems is the parent company of Naviquis. Naviquis utilizes HealthWare Systems' cutting-edge technology infrastructure to provide its FWA management solution. The SOC 2 certifications were achieved by HealthWare Systems and apply to Naviquis' infrastructure.
• I.S. Partners, LLCminorImplementation/ SI/ Consulting Partner · 17 July 2023I.S. Partners, LLC is a globally recognized CPA firm that conducted the SOC 2 Type I audit and certification process for HealthWare Systems (Naviquis parent company). They performed a comprehensive evaluation concluding that security policies and procedures are in compliance with industry best practices.

Scale indicators8 records

Recent moves6 records

Expansion highlights4 records

Direct peers

• Zelis: Zelis offers healthcare claim cost management, payment integrity, and provider network solutions to payers and TPAs, putting it in direct competition with Naviquis on pre-pay and post-pay FWA workflows.
• HealthEdge: HealthEdge provides a payer-core technology platform with payment integrity and claims processing capabilities, making it a relevant peer for Naviquis's payer-focused, pre-pay claim analytics approach.
• Inovalon: Inovalon delivers payer-side data analytics, FWA detection, and quality/performance solutions to health plans, directly overlapping with Naviquis's claim analytics and FWA prevention use case.
• MultiPlan: MultiPlan provides healthcare cost management, payment integrity, and claim analytics for payers, TPAs, and self-funded employers, overlapping directly with Naviquis's payer-facing FWA and pre-pay detection proposition.
• Change Healthcare (now part of Optum): Change Healthcare offers payment integrity, claims management, and FWA analytics used by payers and providers, overlapping directly with Naviquis's claim-level analytics and FWA detection capabilities.
• Cotiviti: Cotiviti is a leading healthcare payment integrity and accuracy vendor serving payers and TPAs with pre-pay and post-pay claim editing, FWA detection, and analytics, directly competing with Naviquis's core offering.
• EXL Service (SCIO Health Analytics): EXL's healthcare arm (formerly SCIO Health Analytics) offers payment integrity, FWA, and clinical analytics to payers, directly comparable to Naviquis's payment integrity value proposition.
• Conduent: Conduent provides commercial and public-sector healthcare payment integrity, claims management, and FWA services, competing with Naviquis for payer and TPA contracts.

Emerging players

• FRISS: FRISS is an AI-driven fraud detection vendor for property/casualty insurance with a healthcare-payer extension, representing an emerging, AI-first peer competing for similar payer FWA budgets as Naviquis.

Broad incumbents

• Optum (UnitedHealth Group): Optum operates one of the largest healthcare payment integrity, FWA, and analytics platforms (including Change Healthcare) used by payers nationwide, serving as the dominant incumbent Naviquis must compete against.

Market position

Strengths4 records

Weaknesses4 records

Competitive moat4 records

Key risks6 records

Key highlights6 records

Customer concentration

• Xx.com/naviquis
• Facebookfacebook.com/naviquis
• LinkedInlinkedin.com/company/naviquis

Compliance2 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles1 record

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about Naviquis