Healthcare Data Interoperability

Attachment Management

Accelerate Claims Processing By Leveraging Electronic Claims Attachments.

With More Than 200 Million Claims Attachments Exchanged Annually And 84% Of Them Through Email, Fax, Or Web Portals—Processing Claims Can Be A Tedious, Costly, And Abrasive Process. Enable Operational Efficiency, Provider Collaboration, And Faster Reimbursement With The Secure, Automated Exchange Of Attachments. Attachment Management Integrates With Existing Backend Systems And Matches The Right Attachment To The Right Member And The Right Health Plan – Providing End-To-End Tracking And Transparency.

Cross-Enterprise Workflow

Review internal workflow with dashboard visibility

Scale provider onboarding with bulk load

Support solicited and unsolicited modes

Receive attachment receipts and email notifications

Resolve problems proactively through task transparency

Deep System Integration

Integrate with existing document management systems

Collect medical documentation using any channel

Route to existing backend systems

Scale to meet emerging business initiatives

Optimize claim adjudication, risk adjustment, and quality metrics

Secure, Automated Exchange

Request and exchange attachments electronically through multiple communication channels

Link the provider response to the claim

Support member requests for information

Receive responses directly or through a portal

Meet FHIR “safe harbor” and emerging standards.

Operating Rules

Achieve And Maintain Operating Rules Compliance

The Patient Protection And Affordable Care Act (ACA) Mandated That Health Plans Comply With A Series Of Operating Rules Requirements For Administrative Simplification. Non-Compliance Can Result In Substantial Financial Penalties. Edifecs Operating Rules Solution Is A Comprehensive Offering That Provides Health Plans With A Technology Framework To Meet, Monitor, And Report Compliance For Certification With The Department Of Health And Human Services. It Also Enables You To Manage Transaction Workflows For All Phases And Is The Only Authorized Solution For CAQH CORE Certification.

Analysis and Assessment

Conduct business process and gap assessments for implementation

Identify current performance levels and gaps requiring remediation

Receive recommended project tasks and participate in critical path activities from analysis and certification, to extended testing, ongoing implementation, and monitoring of the Operating Rules.

Ongoing Surveillance to Track Operating Rule Compliance

View executive-level dashboards for visibility into overall compliance levels in accordance with reporting and documentation requirements

Gain access to interactive detailed dashboards for compliance levels, including response time SLAs, transactions and acknowledgments balancing, AAA Error reporting, 271 data content validation, and more

Receive business alerts and notifications to facilitate timely compliance review and action.

Production Level Testing to Identify Implementation Gaps

Perform production level testing

Access comprehensive test cases covering most of data content and infrastructure

Ensure adequate coverage and completeness of test plans

Access intuitive dashboards to identify gaps and errors.

SpecBuilder

Simplify Transaction Specifications With A Professional-Grade Toolkit

Building Accurate And Precise Data Connections Enables Compliance With HIPAA And Operating Rules Mandates, Enforces Business Policies, Enhances Operational Efficiency, And Protects Mission Critical Systems From Failure. Simplify And Accelerate Authoring, Testing And Publishing Specifications And Processing Maps For Transaction Processing With SpecBuilder—An Integrated And Easy-To-Use Specifications Toolkit.

Comprehensive Compliance Capabilities

Achieve compliance with predefined HIPAA, HL7, NCPDP and other guidelines

Define and test transaction with a rich, integrated, visual environment

Enhance data governance and enforce policy with custom business rules

Build test cases for compliance using internal and partner data files

Support validation and data transformation between standard and proprietary files

Intuitive Editor and Extensive Library

Access and use 30,000 pre-built templates

Build maps using standard and proprietary formats or batch files

Reverse engineer specifications from data files

Import and export specifications and data efficiently

More Visibility, Better Data Management

Understand the impact of change and partner errors with integrated reporting

Highlight differences in data files before and after system changes

Create and customize test data from production data

Gain business insights directly from transaction data

Seamless Trading Partner Integration

Share user notes and comments about specifications

Publish guidelines, maps and data files in various formats

De-identify data to protect PHI when sharing with partners

Test partner data files against implementation guidelines.

Transaction Management

Gain End-To-End Visibility And Insight Into The Entire Lifecycle Of Healthcare Transactions

Every Day, Healthcare Generates More And More Data. This Data Must Be Collected And Archived To Comply With HIPAA Regulations. For Many Health Plans And Providers, The Amount Of Data Is Staggering. Transaction Management Correlates Clinical And Administrative Data, Provides Real-Time Visibility Into Transactions, And Enables Self-Service Functionality.

Data Quality Monitoring

Report partner and channel activity and data quality trends compared to norms

Increase automation rates with deep data quality monitoring and what-if analysis

Configure workflow and escalations to correct transactions before they’re transmitted

Get alerts when service-level exceptions occur

Leverage granular role-based control to secure transactions and views

Real-Time Visibility

Receive business-friendly views easily consumed by non-EDI staff

Detect abnormal processing and data patterns with audit and research tools

Access archived data quickly and easily

Track service-level agreements and processing to comply with CAQH CORE response times

Reduce the need for service experts with powerful search functionality

Smart Data Correlations

Organize results based on information need, time, and type of data with rich filters

Report key metrics by type and partner

Uses a timeline view to visually explore data associated with episodes of care and claims.

XEngine Server

Automate And Optimize Data Exchange Across The Care Continuum.

More Than Ever, There’s An Increasing Need For The Real-Time Exchange Of Data Between Organizations. The Effective Exchange Of Information—Whether Administrative Or Clinical—Is Foundational To Core Business Processes, Compliance, And Value-Based Payment Models. XEngine Server Facilitates The Exchange Of Information At Specific Points In The Care Continuum, Interacts With A Variety Of Existing Information Systems, And Consolidates Transaction Streams Leveraging A Unified Gateway.

Automated Performance Management

Detect and notify message backlogs, peak loads, and low volumes by partner, time period, and more

Ensure process completeness and prevent costly rework

Monitor activity outside the expected minimum or maximum range

Address potential issues with customizable alerts and notifications

High-Quality Data Exchange

Integrate clinical and administrative data into a unified front-end system

Catch errors early and prevent failures in downstream systems to increase the first-pass rate

Validate data elements against more than 60+ code sets

Connect via more than 30 industry protocols and exchange methods

Identify and track problematic behavior to resolve issues quickly

Real-Time & Batch Interoperability

Automate management of control functions

Ensure compliance with healthcare mandates, state regulations, and enterprise guidelines

Consolidate disparate channels into a single, unified front-end system

Transmit outbound batches automatically based on schedule, volume, or custom criteria

Automate message processing and routing rules to reliably deliver clean data.

XEngine Server For FHIR

Enable Healthcare Interoperability With FHIR APIs

The Evolution Of Healthcare Consumerism, And CMS Mandates, Has Accelerated The Need For Patients To Access Their Personal Health Information Anytime From Anywhere. XEngine Server For FHIR (Fast Healthcare Interoperability Resources) Streamlines And Standardizes The Exchange Of Clinical And Financial Data Between Health Plans And Providers, Ensuring Real-Time Interoperability And Compliance.

Bi-Directional Integration

Integrate between FHIR and existing back-end systems and workflows

Adopt FHIR standards quickly with basic or no prior experience

Extend the capacity of existing systems, clinical repositories with FHIR to any partner

Aggregate HL7 transactions to trigger timely interventions at the point of care

Simple Platform Experience

Configure the experience to fit your organizational needs without compromising compliance

Engage members with access to resources and apps

Enable third-party ease of access and compliance with value-add features

Get a hosted solution with Zero technology footprint

Provide outstanding level of customer service with business friendly views of FHIR data

Standardized FHIR APIs

Support value-based care initiatives through Da Vinci Project use cases and FHIR Resources

Access standards database with out-of-the-box guidelines for HL7 FHIR (DSTU 3 and higher)

Jump-start the development of FHIR-based projects with proven technology

Decrease time to market by leveraging the flexibility and ease of FHIR

Get pre-built FHIR maps between other industry standards.

XProcess Management

Improve Efficiencies, Reduce Costly Errors, And Grow Your Business.

Health Plans Have Extremely Complex Processes Involving Multiple Systems Making It Difficult To Locate A Single File At Any Point In The Process And Determine Its Status. This Lack Of Visibility Directly Contributes To Process Delays, Unreimbursed Encounters, Breaches Of Vendor Service-Level Agreements, Broken Continuity Of Care, And Disrupted Enrollment. XProcess Management Is A Healthcare-Focused Business Process Management Solution That Enables Greater Insight Into Processes And Leverages Results To Sharpen Your Competitive Edge And Accelerate Business.

Critical Business Insights

Reduce the number of unreimbursed encounters by identifying and fixing errors early

Identify financial penalties incurred and correlate them back to specific errors

Optimize claims-to-encounters ratio

Visualize your data across all your processes simultaneously

Resolve process delays associated with inefficiencies or bottlenecks

End-to-End Visibility

Identify complex processes that need to be simplified and streamlined

Confirm that gaps in care are closed without having to chase down charts

Receive real-time notifications of errors and rule violations

Gain visibility into external systems and their impact on bottom line

User Friendly Experience

Ensure enterprise-wide service-level agreement compliance by closely monitoring performance

Save time searching for missing patient information

Avoid “black-hole syndrome” where data is held up in between two systems

Receive events from any third-party system (REST/XML or via proxy channels).