Full X12 healthcare EDI transaction coverage for the revenue cycle
Physician, outpatient, ancillary claims. Loops 2000A–2400, NM1/CLM/SV1 segments. All payers and clearinghouses.
Hospital, facility, inpatient claims. Revenue codes, DRG, UB-04 data elements. CMS-1450 mapping.
Electronic Remittance Advice parsing — CLP/SVC/CAS/MOA segments, CARC/RARC codes, ERA-to-payment posting.
Real-time eligibility inquiry (270) and response (271). Co-pay, deductible, out-of-pocket, active coverage status.
Claim status inquiry (276) and response (277). Accepted, rejected, pending, denied — with reason codes.
Prior authorization request (278-request) and response (278-response). Medical and pharmacy PA workflows.
Benefit enrollment and maintenance — member add, change, terminate. Employer/TPA-to-payer benefit setup.
Premium payment and remittance from employer or TPA to health plan. EFT/ACH integration.
Availity, Change Healthcare (Optum), Waystar, Trizetto, Office Ally, ABILITY/Inovalon. Enrollment, testing, go-live, monitoring. Trading partner setup and connectivity.
Direct EDI or API connections to Aetna, UnitedHealth Group, BCBS plans, Cigna, Humana, Centene, Molina. HIPAA 5010 compliance and payer-specific companion guides.
Connect your EHR or practice management system to the EDI workflow: Epic, Cerner, athenahealth, eClinicalWorks, Kareo, AdvancedMD, Meditech, Greenway.
999/TA1 acknowledgment handling, 277CA validation response processing, SNIP Level 1–7 validation, payer-specific edit enforcement.
Build or modernize EDI translation middleware: EDI→JSON/XML transformation, event-driven processing (AWS SQS/SNS, Azure Service Bus), retry/error handling, audit logging.
End-to-end revenue cycle: eligibility check → claim submission → status tracking → ERA posting → denial management → secondary billing. AI exception handling for denied claims.
Fixed price in USD. Source code ownership. 60% of US healthcare IT rates.