Enable data transparency

Derive business intelligence from your data transactions.

Transaction Management

Improving service and increasing operational efficiency requires a 360 degree view of document exchange between partners. Everyday, healthcare generates more and more digitized data. This data must be collected and archived to comply with HIPAA regulations or generate performance reports. For many health plans and providers, the amount of data is staggering. Access to current and archived data is essential to adjudicate claims, resolve issues and respond to partner queries.

Our Approach

With Edifecs Transaction Management, you can correlate clinical and administrative data, provide real-time visibility into transactions, and enable self-service functionality to business and technical teams. Leverage industry-leading member and family views to visually explore encounters, episodes of care and claims.

Our product unlocks data to reduce operation costs, improve service, and provide medical necessity to enable better care coordination.

Capabilities

Monitor partner interactions

Organize all partner interactions into one integrated repository, then activate insight through dashboards and status tracking at summary and detailed levels.

  • Track the entire lifecycle of a healthcare transaction, such as claim, eligibility request, claim, claim status request or enrollment.
  • Generate scheduled or on-demand reports including metrics, trends, balance and ad-hoc queries.
  • Configure automated alerts to notify business and IT users when processing exceptions occur.
  • Trigger review when exception conditions are met and use workflows with escalations to correct exceptions.
  • Comply with retention policies and meet audit requirements through searchable end-to-end transaction history.

Partner self-service capabilities

Manage and control partner profiles and connectivity preferences while monitoring performance and sharing results.

  • Provide partners with a secure self-service portal either stand-alone or integrated into existing enterprise portals.
  • Enable self-service testing and viewing of transmitted data to ensure partners can create compliant claims.
  • Create reports that can be auto-generated and delivered directly (FTP, SFTP, email) to internal users and external partners.
  • Aggregate data reporting to streamline SLA management and volume/reject management by partner and document type.
  • Monitor daily volumes and rejections and use automated reporting functions to identify trends and conduct error analysis.

Member activity tracking

Leverage industry-leading member and family views of correlated clinical and claims data to visually explore encounters, episodes of care and claims.

  • Construct member profiles and build relationships with covered dependents from all data flowing through the gateway.
  • Search for member activity across all transaction types, then filter to refine search results.
  • Use unstructured search to find all transactions containing a matching value in any field.
  • Organize correlated transactions in a timeline view, then zoom-in to a day or zoom-out to a year.
  • Display human readable EDI and clinical data including ADT, CCD, patient discharge and referral summaries.

Archive and audit

Transaction Management Archive reduces the cost of record keeping and increases flexibility to quickly respond to data requests.

  • Enable non-technical users to quickly find records to support audit inquiries or discovery requests from legal teams.
  • Comply with legal requirements to maintain detailed transaction data for up to eleven years or longer.
  • Respond quickly to member requests related to claims, payments or other business processes. Locate and analyze specific transactions using sophisticated structured and unstructured search tools.
  • Efficiently move historical transaction data to archive storage to free up resources and reduce educe storage costs.

Transaction corrections

Transaction Corrections is a powerful tool to reduce the cost of compliance and increase automation rates.

  • Reducing manual effort and avoid noncompliance with CORE Operating Rules by preventing processing delays.
  • Enable corrections to many transactions (834, 835, and 837), for example, out-of-balance conditions and inbound enrollment files from exchanges.
  • Complete set of workflow tools include tasks, queues, updates, review, approval and escalation processes, and security features.
  • Manage the end-to-end exception resolution process with industry best practices and workflows that leverage Business Process Modeling Notation (BPMN).