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Health Insurance Plans and TPAs

Save on EDI and CMS and migrate from #EDIFix

  • Modernize X12 EDI Gateway ​using  HiPaaS Healthcare Interoperability Platform with AI

  • Migrate from Legacy EDIFix to HIPaaS EDI gateway's and we guarantee 60% savings on cloud computing and operations via automation

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HiPaaS platform is built with automation and to save Cloud using serverless technology. 
We Guarantee savings of 60% compared to existing #EDIfix 

Automate all EDI Transactions with HiPaaS EDI Gateway

Consolidate EDI gateway and Interoperability capability in one platform. Reduce operational and licenses cost. Improve provider and member experience with single source of information. Integrated with Availity and leading Clearing houses. Automate EDI Validation SNIP L1-L7 and reduce edi errors. Manage your membership with medicare, medicaid, Medical and other state plans.

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Enable ONC CMS Interoperability and Clinical Data Integration in one platform

  • Make your EDI data usable by enabling the Healthcare FHIR Server via APIs to others

  • Use same data for operational analytics, predictive analytics, generative AI. 

  • Use same data for down stream systems and customer operations. 

  • Enable same data for CMS Interoperability

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Integrated with multiple claims systems

Pre Integrated across leading Health plan applications

Integrated with QNXT, EPIC, Facets, Healthedge and others. Integrated with leading clearing houses and providers like Availity, HPS and others. Everything is API and can easy plug and play. Enable Claims Edits and real time claim submission

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Case Studies

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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

HiPaaS EDI Gateway Capabilities

All X12 EDI Transactions

Enable all EDI transactions: 837 (I, P, D), 835, 834, 820, 270/271, 276/277, 278, 275, 274 

Enable Real time and batch transactions

Enable inbound and outbound transactions

Convert EDI to Json and FHIR

Pre-Integrated to QNXT, Facets, Healthedge and Epic

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Enable EDI faster with pre-built EDI templates

Point and start mapping EDI Transactions
With HiPaaS Platform, validate, map data. 

Configure data validations, conversions and business rules for mapping. 

Add SNIP L1-L7 Validation and Conversion Rules

Add EDI edits, AI driven validations for SNIP L1-L7

EDI validations with custom rules

Integrate with enterprise services

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Enable FHIR and CMS Rules on same platform

Enable  CMS Interoperability and Patient Access Final Rule (CMS-9115-F).

Enable Prior Authorization proposed rule (CMS-9123-P) . 

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Reconcile and Reporting

Reconcile every claim, claim payment, member eligibility, prior authorization, enrollments, FFS payments and outbound transactions

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What problems we (HiPaaS) are trying to solve

Reduce EDI errors:

Reducing EDI errors that can lead to more load on claims adjudication staff, customer service, delays in payments, and potential compliance issues.

EDI Data challenges:

Addresses the issue in EDI data like eligibility response, claims payment delay, ensuring automatic AI driven fixes in incoming data and automate EDI edits and SNIP level L1-L7 validations.

Administrative inefficiencies:

To streamline administrative tasks related to prior authorization, claims approvals and reducing the administrative burden.

Compliance risks:

By ensuring that the EDI SLAs are met and documentation processes adhere to the constantly evolving regulatory requirements and standards in the healthcare industry.

Provider and Patient dissatisfaction:

HIPAAS contributes to a more transparent EDI process, leading to improved providers and patient satisfaction and trust in the healthcare.

 

Operational inefficiencies:

HIPAAS helps in identifying and addressing operational inefficiencies, thereby automating the overall EDI performance and sustainability of the healthcare organization.

What we (HiPaaS) provide

  • Efficient EDI Operations: HIPAAS provides robust framework comprising of individuals and technology to reduce administrative burdens and allows healthcare providers to focus more on patient care and operational efficiency.

  • Data-driven edits:  HiPaaS tools analyzed EDI data to identify areas to automate, cost-saving opportunities, and strategies for enhancing the overall EDI performance of the healthcare organization.​

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​​HIPAAS EDI Transactions:

  • 837 I, P, D: Validate and Load incoming claims files. SNIP L1-L7 validations.  Generate 999, TA1, 277CA. Link 835 ERA, 276/277. Generate Outbound 837 I, P, D.  Standard and Custom Edits. Automated Data Corrections and simplified Trading Partner management. Enable Claims edits and claims updates. 

  • 835 Remittance Advice, ERA : Generate or Receive 835 files. Validate and load the files. Reconcile with 837 claims files

  • 834 Enrollments and Full File Compare: 834 File Validator and Loader. Support multiple Formats for 834. Compare with Membership before loading. Full file compare , Audit file compare. Check PCP, rate codes, dual plans, coverage, retro changes. Generate Outbound 834 for providers, Generate Outbound custom membership files for providers. Track Membership data to ID card generation

  • 270/271 Real time or Batch Eligibility: Enable Realtime and Batch 270/271 Transaction with CORE Compliance. Integrated with HETS and CMS connectivity. Route request to multiple membership systems. QNXT, QXI integration. Availity Integration. Convert Response to EDI and JSON for multi channel support.

  • 276/277 Claims Status: Enable Realtime and Batch 276/277 Transaction with CORE Compliance. Integrated with HETS and CMS connectivity. Route request to multiple membership systems. QNXT, QXI integration. Availity Integration. Convert Response to EDI and JSON for multi channel support.

  • 278 Prior Authorization: Enable Realtime and Batch 278 Transaction. Track every Prior Auth request and Response. Route request to multiple systems. Track attachments and additional requested data

  • 820 Payments: 820 File Validator and Loader. Compare Premium files with Eligibility data. Compare retro payments. Identify discrepancies in premium payments. Compare with outbound Provider payments. Generate Premium reports.

  • 275 Attachments: Enable 275 EDI Transaction. Receive and track attachments. Link Attachments to claims and Prior authorizations.

  • 274 Provider Directory: Generate 274 Provider Directory from QNXT. Generate Network coverage. Submit to Medicare

 

  • Encounters Submission: Submit accurate Encounters to State and Medicare. Validate based on State Edits. Reduce Encounter rejections. Correct data manual before submission. Auto data correction based on state rules. Track Encounter responses from state. Fix encounter rejections and resubmit. Increase acceptance rates 

  • Enable EDI via FHIR API:  Enable all EDI transactions as FHIR API

  • SNIP L1-L7 Edits and Validations: SNIP L1-L7 Validations and Smart correction on repeating data error. Automated AI learning rules to correct data.  Companion guide and rules Templates by trading partner. Audit every change and transaction

HIPAAS Differentiator

  • Next Generation Technology: HiPaaS EDI Gateway is built on next generation technology with Neo4j Graph DB, Boomi mappings, Kubernetes, DevOps and more. 

  • AI driven EDI Validation: HiPaaS EDI Gateway uses inbuilt Machine learning models and AI to validate data and EDI rules. 

  • Maximizing EDI pass rate: It encompasses various strategies and processes aimed at increasing EDI pass rate and minimizing rejections. It involves validation, automatic data corrections, rejections based on rules, timely 999 and 277CA responses.

 

  • SLA and Compliance: HIPAAS proper management of the EDI ensures that the healthcare facility remains compliant with the complex and ever-evolving regulatory requirements  and also meets the SLAs.

 

  • Accurate edits and audit Techniques:  Accurate edits and audits of data is what HiPaaS is different from others.

 

  • AI Tools: Wherever possible HiPaaS uses AI Tools to automate data corrections

  • Low cost :  Low cost is another differentiator HiPaaS architecture as we are built on auto scalable architecture

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