Edifecs is a global health information technology company providing a comprehensive, cloud-native platform for healthcare data management, interoperability, and payment optimization. The platform is a market leader in the healthcare ecosystem, trusted by over 300 leading healthcare organizations, including 100% of national health plans and 70% of state Medicaid programs.
Product Overview and Key Benefits Edifecs' core value proposition is to unify, normalize, and exchange clinical and financial data across the healthcare network to reduce administrative waste and ensure compliance. The platform leverages machine learning and AI to power Robotic Process Automation (RPA) and predictive capabilities, extracting meaningful insights from complex data. By consolidating fragmented data streams into a centralized hub, Edifecs helps organizations improve business functions, mitigate risk, ensure payment accuracy, and effectively scale their value-based operations.
Main Features and Capabilities
- Healthcare Interoperability: A unified gateway supporting all data standards, including FHIR, X12, EDIFACT, HIPAA, and HL7, enabling secure and effective data exchange between payers and providers.
- Regulatory Compliance: Solutions for ongoing compliance with mandates like HIPAA, ICD-10, and CAQH CORE operating rules, often acting as a CMS-approved vendor for verifying industry data.
- Value-Based Payment Management: Cloud-native solutions for Population Payment Management, risk adjustment, and prior authorization, designed to help organizations thrive in alternative payment models (APMs) and ensure accurate care funding.
- Enrollment and Claims Management: SaaS-based solutions for automating and streamlining member enrollment and claims processes, including automated routing, error correction, and financial reconciliation.
Target Users and Use Cases Edifecs primarily targets large-scale healthcare entities: Health Plans, Healthcare Providers, and Government Agencies. Key use cases include: achieving and maintaining regulatory compliance (e.g., CMS Payer Interoperability), optimizing revenue cycle management in value-based care, and reducing administrative costs through data automation and quality improvement.
