Client Background
The client is a US-based healthcare technology company that provides services to payors and providers across all healthcare programs, including Medicare, Medicaid, Commercial and Exchange.
Client Need
- Solution to collect, save and validate the Encounters information, from different health plan systems, received in EDI 837I/P/D format
- Acknowledge the Encounters received from different vendors
- Encounters submission to CMS – RAPS, EPDS (post adjudicated files in the form of EDI 837I/P/D files)
- Sharing 277 CA (Encounter Acknowledgement) , MAO002 and 999 Electronic Encounter responses, received from CMS, with the vendors
Our Solution
Developed an encounter management system from the scratch which can be easily integrated with the core system, process the complex data, track and transform eligible adjudicated claims into encounters, accelerate response to regulatory changes and maximizes reimbursements with improved acceptance rates
Built a system:
- To accept and validate adjudicated EDI 837 Encounters from various health plans and provide acknowledgement
- Read post adjudication Encounters and check encounter eligibility for submission based on configured business rules
- Submit ( to CMS) and track responses of all encounters and reconcile them
- Share 277 CA and 999 responses received from CMS with the vendors
Tools & Technologies
RDPCrystal EDI Library, .NET Core, Microsoft SQL Server, RabbitMQ, Power BI
Key Benefits
- Streamlined the Encounters intake and submission process thereby increasing efficiency by 30%
- Improved CMS acceptance rate from 96.5% to 98.5%
- Made reconciliation process easy by tracking all encounter submissions and responses from CMS
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