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Healthcare EDI Gateway Automation using AI

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SIMPLIFY HEALTHCARE ADMINISTRATION. SNIP L1-L7 AUTOMATION

OUR ViSION

We're here to reduce Administration cost using AI

HIPAAS EDI GATEWAY FUNCTIONALITY

Integrated with QNXT, Trizetto, Healthedge, EHRs, Generative AI to manage EDI 

EDI Gateway

Payers and TPA can receive and validate all EDI transactions; 837 (I, P, D), 835, 834, 820, 270/271, 276/277, 278, 275, 274. Receive paper claims and paper prior auth. Enable Real time and batch transactions

We support L1-L7 validation, Claim edits, reconciling inbound and outbound transactions. CORE compliance, CMS and HIPAA compliance EDI gateway. 

Enrollments Management (834)

Inbound 834:

Manage all inbound claims 834 from various Trading Partners, Clearing Houses, Medicaid, MediCal, CMS and Large Groups. Configure custom 834. Validate Claims L1-L7, send 999. Auto corrections using our smart AI Capability.

834 Audit , Full File and Daily File:

Compare Audit full file with membership before processing it to find differences - PCP changes, demographics changes, rate code changes, dual plan codes, coverage, retro coverage and more. Resolve data issues before loading to membership

Outbound 834:

Generate outbound 834, receive and reconcile 999.

Realtime and Batch 270/271 EDI Transaction:

Enable real time and batch Eligibility status check using 270 transaction

275 Attachments 

275 Attachments:

Enable real time and batch claims and prior authorization attachments

278 Prior Authorization

Manage end to end prior authorization. Receive prior auth, approve or request additional data. Map prior auth to submitted claims. Claims and Prior Auth data available in one place.

Claims Validation and Claims Fraud Management using Generative AI

Integrated Gen AI to validate claims, pend claims, reject claims,  approve and denial claims. Validate every inbound claims with set of predefined rules, historical data and patterns. Identify and detect Claims fraud patterns.

Claims Administration (837)

Inbound 837 I/P/D:

Manage all inbound claims 837 I/P/D from various Trading Partners, Clearing Houses and Providers. Validate Claims L1-L7, send 999, 277CA. Auto corrections using our smart AI Capability.

Claims Attachments:

Manage all inbound claims attachments and assign to claims

Claims Edits:

Edit inbound claims and resubmit

Outbound 835 Claims Payment:

Generate and reconcile outgoing Claims Payments 835 files. Manage 277CA and Denials. 

Data Entry for UB04 and CMS-1500:

Simple data entry screens to manually add claim and claim payments

Outbound 837 I/P/D:

Generate outbound 837 I/P/D, receive and reconcile 999, 277CA and 835 payments.

Realtime and Batch 276/277 EDI Transaction:

Enable real time and batch claims status check using 276 transaction

Realtime and Batch CORE Transctions

CORE Compliance and integrated with CMS and Plans


270/271 Eligibility:

Enable real time and batch Eligibility status check using 270 transaction. Enable FHIR

276/278 Claims Status:

Enable real time and batch claims status check using 276 transaction

278 Prior Auth:

Enable real time and batch prior Authorization check using 278 transaction and attachments

274 Directory

274 Directory:

Enable Network directory and submit it to CMS or state

820 Payments

Load, Validate and Reconcile 820 Payments with membership data, retro charges, pcp charges, outgoing provider payments. 

Claims Payments and EOB

Automatically reconciles 837, 835, electronic remittance advice (ERA), treasury records, lockbox transactions and Self Pay. Compare 837 and ERA side by side. Auto load paper claims and ERAs.

We also automatically identify self pay and integrate to payment. Easily upload your self pay payment files, lockbox files and automate payments, Generate EOB statements

EDIVal - AI Driven EDI Functionality with Smart Corrections

EDI Gateway

Payers and TPA can receive and validate all EDI transactions; 837 (I, P, D), 835, 834, 820, 270/271, 276/277, 278, 275, 274. Receive paper claims and paper prior auth. Enable Real time and batch transactions

We support L1-L7 validation, Claim edits, reconciling inbound and outbound transactions. CORE compliance, CMS and HIPAA compliance EDI gateway. 

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Work Queues

Enable work queues to hold data for manual corrections or review. Easily setup multiple work queues for business to review data

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Simplified Dashboard

Simplified dashboard for business and technology team to review and quickly find the issues or required SLA metrics

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Integrated with Generative AI

Integrate any transaction to Generative AI or other real time AI platforms

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Reconcile EDI Data

Automatically reconciles 837, 835, 999, 277CA, 276/277, 275

Automatically reconcile prior auth to claims and attachments 278/275

Generate single view of member - with all transactions

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Simplified Reports and BI

Generate all reports required to manage EDI transactions. Integrate to any BI Tools and generate dashbaords

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Validation Rules and Lookups

100+ Lookups available - code sets, icd codes, covered , not covered, language, rate codes, and more

Ability to define complex validation rules using HiPaaS Rules engine

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Smart AI Data Corrections

Smart AI data corrections offers ability to change data on the file using historical data knowledge or rules defined data ability

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Validation Rules Templates

Define validation rules and save templates for applying it to trading partners, line of business, or clearing house data.

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Technical Errors and Exceptions

Easily track down technology failures, code exceptions, integration issues in single place

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Easy Data Entry and Corrections

Easy data entry to add new claim or claims payments, enrollment or correct inbound transaction data

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Everything Rest API

Integrate to any application or call any API for validation rules or data corrections

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Our Client Success

Working with the Best Healthcare Companies

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Case Study

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Molina uses HiPaaS EDI Gateway to enable all EDI transactions across 18 states Medicaid, Medicare and Marketplace line of business

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San Francisco Plan uses HiPaaS EDI to enable full file compare with DHCS

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Enabling CMS Interoperability across 5 states

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Medica mordernizing EDI with HiPaaS EDI Gateway

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San Francisco Plan uses HiPaaS EDI to enable full file compare with DHCS

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Supporting Eligibility for 50K+ Providers across US

Claims Administration in Numbers

90M

Claims

30%

Reduced Manaual Cost

25%

Fraud Detection

95%

Increase in timely response

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Request Demo

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