Claim Insight

EDI gateway, data repository and data quality platform for healthcare claims

EDI Gateway Functions

Parse, save and convert X12 EDI and NCPDP files with minimal effort

  • Support for medical and pharmacy claims and payments in X12 EDI, CSV and NCPDP Telecommunication Standard formats
  • Ultra-fast parsing and file ingestion
  • Files can be loaded directly from cloud storage, such as AWS S3, and Azure blob storage
  • All codes are enriched “on the fly” with descriptions and other metadata
  • Export to JSON and FHIR, relational and NoSQL databases
  • REST APIs for searching claims and payments and accessing analytics

Billing and Payment Integrity, Data Quality

Catch a wide range of billing and general issues

  • Extensive rule-based analysis using industry-standard Medicare’s National Correct Coding Initiative Edits (NCCI) and Medicare Code Editor (MCE) edits
  • Suspicious billing anomaly and outlier detection
  • Identification of duplicate claims
  • Support for a manual review workflow with statuses and notes
  • Strict validation against X12 EDI specification and reference code sets

Claims Analytics

Unlock the wealth of information hidden in claims

  • Understand your key metrics, including billed and paid amounts and claim volumes
  • Group and filter by providers and specialties
  • Gain insight into procedures, diagnosis, institutional billing codes
  • Perform temporal analysis, including trends and spikes over time
  • Understand your patient demographics and their conditions: group and filter by age, gender, location

Reference Data Set Management

Reference data sets are taken care off, automatically

  • All codes are automatically annotated with descriptions and guidelines from authoritative sources
  • Reference data sets include ICD, CPT/HCPCS, NDC, Type of Bill, and many others
  • Updates are applied as soon as a new version is released; historical codes are preserved
  • Procedure codes classification using BETOS/RBCS
  • Support for provider taxonomies, adjustment codes, and X12 codes

Super-User Friendly UI

Claim Viewer and EDI Viewer for Mere Mortals

  • Intuitive search and filters to quickly find what you need
  • 100% of fields from claims and payments, nicely formatted and logically grouped together
  • Information about codes and providers is always only a click away
  • Tag claims and other items, so you can quickly find them later
  • Share your work items with your team