Healthcare Solutions | Unified Operations

Healthcare organizations need accurate, timely and complete information from employers, brokers, providers and trading partners in order to function efficiently. Fragmented information channels and multiple core processing systems make it difficult to obtain a unified record of transaction activity, to troubleshoot and resolve support issues, and to keep enrollment files and payment records balanced with original transaction submissions.

The Edifecs Unified Operations solution performs healthcare-specific business processes and business rules at the front-end of the enterprise. The solution manages enrollment, claim and payment documents as they are received using multiple intake mechanisms and are routed to core processing systems. The Unified Operations solution ties together related transaction documents such as claims and payments even though the documents may be processed using many different core processing systems.

The Edifecs Unified Operations solution integrates business processing information with the information in back-end systems. It then makes this information available to internal users through reports and visibility tools. Trading partners get access to the partner-specific integrated information through secure self-service portals. The Edifecs Unified Operations solution also includes monitoring and alerttools to detect errors or variances against targeted service levels so that internal operations staff can respond to problems quickly.  

• Improve efficiency of enrollment updates and audits by comprehensively processing and checking enrollment files for errors in a variety of formats and submission methods (including comparison of full-files from employers and internal membership systems to determine updates). 
• More rapidly correct provider claim errors using front-end validation to identify provider format and business rule errors. Initiate corrective action before claims enter adjudication systems. Allow trading partners to view the status of submitted claims and correct using a self-service portal.
• Efficiently route claims to internal or external systems for processing based on member, provider or network selection criteria and then generate HIPAA 837 transactions for external processors such as 3^rd party pricers. 
• Improve accuracy and minimize effort required to generate HIPAA compliant payment documents(including HIPAA 835)across multiple health plan adjudication systems while reconciling adjudication and payment information with original submitted claims and service lines.

Edifecs Unified Operations solutions are based on the following products:

• Edifecs Enrollment Management
• Edifecs Claim Management
• Edifecs Payment Management