Leaders in next generation healthcare integration platform for healthcare insurance companies.

HiPaaS is a next generation healthcare EDI integration platform for insurance companies with microservices an APIs. HiPaaS provides all EDI transactions and trading partner management with pre-integrated business processes around existing Facets, QNXT, and legacy claims systems.

HiPaaS EDI Transaction Tracking and Reconciliation

HiPaaS Database tracks every event and transaction as data is exchanged by payers. The payer solution focuses on audit, compliance and traceability. We also have developed business rules to ensure reconciliation of data and comparison with Facets, QNXT and legacy. We offer simple front end that can be used to track data and reconcile results. Every claims is tracked till it is paid. Every enrollment is mapped to end system to ensure there are no drop outs. We also offer screens to track transaction errors, edit errors, fix and resubmit data.

HiPaaS EDI Solution

837 Claims Intake

HiPaaS offers out of box process to enable 837 I, P, D intake from any provider and trading partner. Trading parner management, mappings to QNXT and Facets are out of box. Inbuilt HIPAA L1-L7 validations or plugin to existing validations. Inbuilt calls to check Provider NPI, Member validations. Every file is tracked, every claim is tracked and every line item is tracked -stored in our robust database. The same transactions are used to status, audit and compliance. We also have logic for generating outbound 837 files and encounters. We provide dashboard to track and reconcile.

837 Claims Edits

HiPaaS offers mechanisms to route and automate claims edits. Simple screens are provided to edit the claims and then either resubmit or notify the trading partner and providers.Every file is tracked, every claim is tracked and every line item is tracked -stored in our robust database. The same transactions are used to status, audit and compliance. We also have logic for generating outbound 837 files and encounters

835 Claims Payment Management

HiPaaS offers mechanisms to route and automate claims edits. Simple screens are provided to edit the claims and then either resubmit or notify the trading partner and providers.Every file is tracked, every claim is tracked and every line item is tracked -stored in our robust database. The same transactions are used to status, audit and compliance. We also have logic for generating outbound 837 files and encounters

Enable Claims Status 276/277

Payers can enable JSON based Claim Status REST service for members, providers and trading partners.  Real-time Claim Status API for 276/277 .

  • Generate complete set of Claim Status data in JSON on request
  • Real-time Claim Status Rest/Json based API for integration
  • Connected to leading Facets, QNXT, Mainframe, Medicare HETS/CMS, Medicaid, State exchanges.
  • No EDI or healthcare knowledge required.
  • Easy to read and understand response in simplified English

Enable 270/271 Eligibility Microservices

Payers can enable JSON based Eligibility REST service for members, providers and trading partners.  #1 Real-time Eligibility API for 270/271 . Our Eligibility Service provides Medical and Dental Eligibility data:

  • Generate complete set of eligibility data in JSON on request
  • Real-time eligibility Rest/Json based API for integration
  • Connected to leading Facets, QNXT, Mainframe, Medicare HETS/CMS, Medicaid, State exchanges.
  • API is connected to Medicare CMS/ HETS to get Medicare Part A, Part B Eligibility
  • No EDI or healthcare knowledge required.
  • Easy to read and understand response in simplified English.

820 Payments – Balance every 820 $ payment against Eligibility!

Payment connectivity and reconciliation offers following functionality:

  • Send or receive standard or custom 820 file formats.
  • Simplified dashboard that focuses on errors and edits
  • Account for every incoming $ from Medicare/MediCal against outgoing provider payments
  • Reconcile every member data payments against membership data, capitation payment against membership data and outgoing provider payments, compare rates, and dual memberships payments against PCP assignments.
  • Identify Retro historical payments

834 Enrollments Submissions

Our Enrollments and Benefits submission provides following:

  • Send or receive standard or custom 834 file formats.
  • Simplified 834 API and services
  • Simple Enrollments dashboard which focuses on enrollments file data, pre-processing and load logic.
  • No member left behind – account for every submitted member data
  • Eliminate spreadsheet with our simplified dashboard that focuses on errors and edits
  • Ensure all trading partners & providers receive the correct membership data
  • Built-in trending of enrollment quality metrics
  • Ensure compliance and audit trail

834 Full File Compare

Enrollment Analytics compares & reconciles member data with external monthly full file 834 against QNXT membership system. It compares the detailed eligibility data, rates, dual membership. GPS also compares outbound membership that is sent to Providers to match the incoming membership data and PCP selections. The errors are highlighted on simplified BI dashboard.

  • Ensure members can access service at point of service, especially on 1st of the month (Rx is most critical).
  • Automate Monthly Full File Compare
  • Improve FAME Monthly processing time from weeks to few hours
  • Compare 834 data element with Membership data
  • Identify Rate mismatch, Dual coverage mismatch and PCP differences
  • Identify Retro historical changes
  • Ensure all trading partners & providers receive the correct membership data
  • Gather & trend enrollment quality metrics
  • Identify and Fix errors in membership data
  • Ensure compliance and audit trail
  • Identify and Fix technical errors

EDI Integration using API -Trading partner Management

Enable EDI X12 Transactions. Pre-built connectivity to leading insurance companies (BCBS, Kaiser, Cigna, Anthem, United Healthcare , Aetna, and others), Medicare HETS/CMS, Medicaid, and State exchanges. Record and track every transaction.

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