Modernize, Modularize, Maximize

COTS based modular solutions to maximize data quality and drive payment reform initiatives

Government Agencies

Based on 20+ years of offering cutting-edge software solutions to health plans, Edifecs has developed many use cases for government agency clients and have expanded the capabilities of our products to meet the needs of those clients. We understand that government agencies face an ever-increasing variety of data and a complex regulatory landscape. By leveraging our suite of software solutions and healthcare domain expertise, we enable state Medicaids and federal agencies to overcome these challenges and achieve the Triple Aim of better outcomes, lower costs and enhanced consumer engagement.

Our Solutions

Edifecs provides modular software solutions for government agencies that enables interoperability with compliant and correlated administrative and clinical information to reduce complexity and inaccuracies. Our solutions include industry leading data validation/compliance processing and solutions built to support vital state Medicaid processes for Value Based Payment Reform and Encounter Data Accuracy Management.


EDI Modernization

COTS-based approach reduces time to market, administrative and infrastructure costs.

  • Unmatched performance to validate, transform and process healthcare transactions.
  • Deep insights into healthcare transaction lifecycle for proactive interventions and continuous improvement.
  • Manage the compliance lifecycle of rules and mandates that govern healthcare.

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Value Based Purchasing

Operationalize and scale payment reform initiatives.

  • Support simultaneous payment models, each with varying goals and populations.
  • Enable the automation of all program design, monitoring, analytics and settlement in a single solution providing for State and program-level oversight.
  • Increase provider and MCO adoption through reduced administrative burden and actionable insights into program performance.

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Encounter Data Accuracy

Improving Encounter Data Quality for State Medicaid Agencies.

  • Straight Through Encounter Processing (STEP) from MCO/provider intake to TMSIS submission.
  • Encounter lifecycle visibility, error tracking and self-servicing for MCO and state administrators.
  • Pre-built business rules for encounter data quality checks.

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Who We Help

State Medicaids

Edifecs improves data quality, reduces administrative costs and increases value based purchasing adoption for Medicaid Agencies. Our modular, purpose built platform helps consolidate and correlate disparate data sources, drive continuous data quality improvements and automate payment reform programs while ensuring ongoing compliance.

Federal Agencies

We provide CMS, VA and other agencies the scalability and security around projects that require multi-organization transactions across the healthcare continuum and reduce IT and operational costs while adhering to mandates and continuous improvement/data quality goals.

System Integrators & MMIS Module Vendors

In this new modular world, we work closely with our partner community to help them reduce their time to market and increase the value of their solutions. We accomplish this by providing out of the box and continually updated healthcare constructs that enable state and federal agencies to address the most pressing administrative and payment reform goals.

State Exchanges

We provide State Based Exchanges a flexible, streamlined, and purpose-built enrollment management solution, critical to ensuring both near-term and long-term Marketplace success.