Success Story

The client is a prominent post-acute management services company that empowers payers and providers to deliver high-quality home health support through remote care management.

Onboard new health plans and configure secure EDI connections with clearinghouses to integrate with existing patient management systems.

Enable the exchange of X12 278 (Healthcare Service Review Information) EDI prior authorization transactions for automated response and acknowledgement processing, optimizing remote care management workflows.

Develop an orchestration and processing layer to transmit and receive X12 278 transactions in near real-time, ensuring full HIPAA compliance.

Maintain comprehensive tracking, auditing, and logging to ensure transparency and reliability within the home health solutions ecosystem.

Introduced a multi-tenant approach to ingest and process data across multiple health plans.

Generated, validated, and parsed X12 EDI 278 transactions (5010x216 & 5010x217) using third-party ediFabric libraries.

Established robust inbound and outbound pipelines with configurable trading partner endpoints, enabling secure and HIPAA-compliant data exchange.

Implemented comprehensive error handling and reprocessing for outbound EDI 278 transactions and acknowledgements (999, TA1) to maintain transaction integrity.

Developed mapping templates and transformations, and deployed a comprehensive tracking and reporting framework for clear visibility into each transaction’s lifecycle.

Our solutions resulted in:

• 5 health plans and clearinghouses onboarded.
• 12 electronic prior authorizations processed annually.
• 30% improvement in performance, eliminating manual PA data reconciliation.
• 100% automation achieved in X12 278 transaction exchange.