AI-Enabled EDI Validations

First No SQL
Healthcare EDI
Platform

Experience the future of Healthcare EDI with
AI-enabled auto scalable w Kubernetes

Medicare, Medicaid and Marketplace across 18 states
Processing 10M+ Claims data

Remittance Advice Generation
Reconciling 20M Claims payments per year
DHCS Full File Compare
Compare Medicare, Medicaid and DHCS Full file with QNXT and update changes
Medicare HETS Real time Eligibility
Check eligibility with HETS CMS across all channels and multiple systems
Medicare Enrollments Management
L1-L7 Validations, Medicare and state rules for covered and not covered code sets. Improved data quality

HiPaaS AI Enabled EDI

AI enabled EDI validation platform : with automated data correction and work queues. Simplified Trading Partner onboarding and configuration. Companion Guide setup for L1/L2 Validations. Configure validation and compare rules based on trading partner, line of business, state, or transaction types.

837, (I, P, D), 834, 835, 270/271, 276/277, 278, 274, 275, 820, 277CA
Claims Management : Claims validation, automation, claims status and remittance management . Manage automated claims corrections, rejections , claims status and claims payments

Real Time Transactions : Realtime Eligibility, PreAuth management, Claim status, Claims Attachments and Provider Directory

Enrollments Management : Manage inbound and outbound enrollments. Medicare, Medicaid enrollments management. Full file and Audit file compare, Compare with membership data in real time and manage updates

Availity Integration : Out of box integration with Availity Clearing house and QNXT for all transactions

HPS Enrollments Integration : Integrated with HPS enrollments for commercial and group plans to handle multiple coverages.

HiPaaS EDI Transactions

Implement all real time transactions with fastest API driven interfaces integrated with QNXT, Facets and Healthedge. 270/271, 276, 274, 278 Pre Auth
Implement real time transactions with fastest API driven interfaces integrated with QNXT, Facets and Healthedge for Claims Status 270/271, 276, 274, 278 Pre Auth

Robust Prior authorization solution for real time and batch 278-11 and 278-13 processing and inquiry. Pega integration

Implement 275 Claims Attachments and Clinical attachments

Implement Provider Directory and directory submission

Manage Outbound Encounters Submission to State or Medicare, Medicaid. SNIP Level 1-7 validations. 999 and 277CA generation. Outbound Encounters: Generate Encounter data/files from QNXT/System of choice or a staging database. Send validated encounters to state with custom edits. Hold and fix encounters errors. Load responses from different States (EVR, 999, 277CA, 835, text reports). Keep up to date on State validation edits changes
Match your encounter edits to inbound Encounter error corrections and Encounter Reporting.

Manage out of box 999, TA1 and 277CA transactions
Out of box integration wiht Availity Clearing house and QNXT for all transactions

Manage Inbound or Outbound Claims 837 I, P, D from various Trading partners, Clearing houses. SNIP Level 1-7 validations. 999 and 277CA generation. Claims Status interfaces. Quickly reconcile rejected claims with mechanisms to route and automate claims edits
277CA transaction response
999, TA1 Responses Account for every $ of claim payment. Reconcile 837 to 835 Payments

Manage Inbound or Generate Outbound 835 Claims Payments. Reconcile with 837 Claims. Reconcile with Remittance and Treasury and Lockbox.

Manage inbound and outbound enrollments from state, Medicare and Large groups. Compare with membership data in real time and manage updates. Manage Add, terms, changes, voids, term by absence and various overlapping scenarios. Business workflow UI to pre-scrub and validate prior to loading into membership system 834 Enrollment Validation & Processing Compare & reconcile member data against any membership system. Automate your membership updates including retro changes Ability to fix errors on file and re-submit with configurable validations including: PCP, NPI, zip code vs state/address, Rate code comparison, Aid code, Dual plans validation
Compare Full file from Medicare, state plans with Membership and identify changes
Manage 820 Payments and reconcile with enrollments data

Manage Outbound Encounters Submission to State or Medicare, Medicaid. SNIP Level 1-7 validations. 999 and 277CA generation. Outbound Encounters: Generate Encounter data/files from QNXT/System of choice or a staging database. Send validated encounters to state with custom edits. Hold and fix encounters errors. Load responses from different States (EVR, 999, 277CA, 835, text reports). Keep up to date on State validation edits changes
Match your encounter edits to inbound Encounter error corrections and Encounter Reporting.

Integrated with HPS enrollments for commercial and group plans to handle multiple coverages.
Manage various other formats for claims, patient data

HiPaaS EDI Capabilities

Trading Partner Management : Simplified Trading Partner onboarding and configuration. Schedule file pickups and file hold for monthly and daily files. Auto scaling based on trading partner volumes. Trading partner self service setup

Companion Guide setup for L1/L2 Validations :Import or setup companion guide based on trading partner, line of business or transaction types

Configure EDI validation rules : Configure validation and compare rules based on trading partner, line of business, state, or transaction types. Define rules templates and import and export the rules. Ignore rules as warnings or errors. Add API's to rules to call enterprise validation services like member match, npi match and others. Configure transactions to hold based on rules

Auto Correct and auto learn rules and data : Setup auto data corrections and rules based on incoming data conditions .

Auto reconcile rules : Setup reconciliation setups and APIs based on transactions. Example - Claims payments reconciled to claims data. Compare Enrollments.to membership data api, Memebr match api

API driven architecture to integrate to QNXT , Facets, Healthedge and other systems REST JSON API, XML or other interfaces available out of box to integrate to your claims or enrollments systems.

Autoscale Real time transactions Auto scale real time transactions using services. Invoke QNXT, Facets, Healthedge API's for real time transactions data

Work-queues for manual corrections Out of box Standard and customized work-queues for the business user to view and update data.

Business Reporting Dashboards Simplified dashboard to check the validation status, trading partner performance, provider performance

Trading partners & Provider Self service Simplified dashboard to check the validation status, trading partner performance, provider performance

HiPaaS Getting Started

On Cloud :Start using in weeks with our HIPAA cloud option
On Premise : Deploy on your data center or choice of private cloud
Pay as you go : Pay monthly as you use it.

Why choose HiPaaS ?

Kubernetes Cluster

Autoscale with Kubernetes. Deploy on Cloud or On Prem - AWS, Azure and Google supported

Healthcare Neo4j GraphDB

HipaaS Store and retrieves healthcare data in Neo4j GraphDB. X12, HL7, FHIR modeling

Healthcare Interoperability Solved

Support for all Healthcare data formats – EDI, HL7, FHIR, NCDP and more. using Boomi

Secure Healthcare API

Everything is Healthcare API. Access any X12, EDI segment or element via API
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Problem Statement

Today’s healthcare insurance EDI analyst spend a significant amount of time performing routine manual reconciliation and corrections of EDI transactions. Additional complexities in the EDI processes related to validations and custom rules, makes large, unapplied EDIi transactions a common – and constant – pain point and risk area for healthcare organizations.
There is also pressure to covert batch to real time or in time payments of claims and additional data like attachments and preauth required.
The EDI system’s used are traditional COTs software and rules developed many years ago. This restricts the agility of making changes to react to market changes. Additionally enabling new line of business and or M&A makes it impossible to implement quickly. Due to COVID-19 there is surge of medical EDI transactions and memberships, this also requires auto scaling of EDI systems. The old EDI systems need large amount of hardware and software to achieve the scale.
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