Accelerate market growth

Breakdown operational barriers to scale and drive strategic growth while securing revenue streams.

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Revenue Growth

Health plans suffering from multiple encounter systems and manual processes face constrained growth and revenue loss, while risking mandate compliance. To overcome these challenges, health plans must deploy technology that breaks down silos and works across programs and LOBs. This approach delivers economies of scale and enables health plans of all types (government-sponsored and commercial) to accelerate strategic growth while securing revenue streams.

Our Solutions

Health plans have been forced to purchase redundant software platforms to manage related operational areas because of data and process silos. Edifecs Revenue Growth solutions improve encounter management and member enrollment efficiency and accuracy to reduce costs and ensure revenue for Medicare Advantage, managed Medicaid, dual eligible and Marketplace programs in conjunction with standard commercial plan offerings.

Revenue Integrity

  • Integrated, end-to-end encounter lifecycle management for all government and commercial programs including Medicare Advantage, managed Medicaid, dual eligible and the ACA/Marketplace.
  • State-specific managed Medicaid modules to ensure on-going compliance and  challenging SLA adherence.
  • RAPS/EDPS submission and reconciliation for Medicare Advantage designed to reduce complexity and exception fall-out while enhancing resolution and re-submission.
  • Leverage best-in-class business operations, professional services and hosting options
  • Targeting for prospective and retrospective HCC programs to ensure coding accuracy and close gaps in care.

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Enrollment Management

  • Integrated data governance for multiple member markets that is scalable (both vertically and horizontally) to support strategic growth initiatives.
  • Marketplace enrollment and financial reconciliation streamlining subsidy reconciliation and the automated matching of payments to initial enrollments, and the releasing to complete enrollment and effectuation processing.
  • Full file processing for maintenance and audit to identify and create updates for downstream systems while resolving discrepancies via collaborative workflows.
  • Visibility dashboards to enhance insight into transactional activity, transaction status tracking and workflow aging.
  • Employer group self-service portal to facilitate onboarding and enrollment fallout resolution.

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Who We Help

Health Plans

Edifecs ensures health plan revenue accuracy by consolidating and automating enrollment, encounter management and risk adjustment operations. We protect plan revenue streams and drive competitive differentiation through scalable solutions for both commercial and government programs.

Pharmacy Benefit Management (PBMs) Companies

Edifecs enables PBMs to decrease encounter and enrollment data management cost and complexity. Through Edifecs, PBMs can reduce IT burden, mitigate health plan abrasion and ensure differentiation in a highly competitive market.


Edifecs ensures that member enrollments and updates from health plans are processed seamlessly and accurately ensuring no loss of revenue.

State Medicaid Agencies

Edifecs provides ease of integration and accuracy between state eligibility records and encounter data submissions with partner health plans.