MiddleSolve/Healthcare Integrator is a modular electronic data interchange (EDI) healthcare transaction processing and management system that has been designed specifically for HIPAA covered stakeholders handling both standard and nonstandard claims plus the related transactions such as acknowledgements, responses, remittance advice, eligibility, and claim status inquiry. Features include online data collection and delivery, batch processing, trading partner management, real-time statistics, file splitting, and transaction bundling.
It goes beyond the typical front-end EDI-wrapper approach by capturing transactional information from the healthcare provider and payer in an operational data store (ODS). The ODS contains the intelligence used to enable new applications for visibility and control of the business cycle such as activity monitoring, fraud detection, revenue control, and decision support.
Based on multi-layered functionality, MiddleSolve/Healthcare Integrator combines the 24 x 7 availability and real time processing of HP servers with data-centric applications that automate claims processing, enable business-activity monitoring, and integrate claims data with back-end adjudication, financial, and membership systems.
Enterprise integration capabilities provide the foundation layer for EDI management and workflow, such as translations, validations, file management, file transfer, data management, routing, ODS data warehousing, and event scheduling. No additional programming is required; all functions are configurable with a user-friendly GUI presentation.
EDI Gateway functions manage transactions between payers and other HIPAA covered entities such as clearinghouses and trading partners. Application modules process claim, eligibility, remittance, and related transactions, and verify the authenticity of the data as it is passed through the system. Integration with other back-end systems is easily handled and completed transactions are warehoused for delivery to the receiver in either batch or online modes.
Revenue Cycle Auditing features use the ODS to track and link claims, provider, and member interactions. These applications interface with existing adjudication, financial, and membership systems and enable help desk consoles, claim status inquiries, 24 x 7 eligibility and authorization reviews, coordination of benefits across secondary payers, pre- and post-claim adjudications, and system monitoring. All revenue cycle transactions are available within a configurable network of trading partners and adjudication systems.
MiddleSolve/Healthcare Integrator meets key return on investment objectives by:
- Enabling direct connections with providers, trading partners, and value-added networks.
- Preserving investments in existing systems by offering off-the-shelf claims management applications that easily interface with adjudication, financial, and membership systems.
- Stopping financial loss from fraudulent claims and mishandled payments by enabling better visibility to business systems and transactions through an ODS that can track and link transactions.
- Decreasing operations costs by automating handling of routine questions and documentation requests associated with eligibility, claims status, and referrals
