Health insurers, TPAs, and digital health plans are moving claims from batch EDI queues and manual reviews to SaaS control planes that deliver high straight‑through processing (STP), lower leakage, faster provider payment, and audit‑ready transparency. The winning stack unifies EDI and FHIR, embeds pricing and policy rules with explainable reason codes, automates attachments and prior authorization context, and applies payment‑integrity and FWA analytics before money moves. Wrapped with strong privacy/security and provider‑friendly APIs/portals, it cuts days in A/P for providers and administrative costs for payers—while reducing member abrasion.
- Claims value chain: where SaaS fits
- Intake and normalization
- Ingest X12 837P/I/D (pro, institutional, dental) over secure channels; validate TA1/999/277CA; normalize into a canonical claims model and map to FHIR Claim/ClaimResponse for downstream use.
- Eligibility and coordination
- Real‑time 270/271 checks, benefits accumulator lookups, coordination of benefits (COB), other coverage discovery, subrogation flags.
- Prior authorization and clinical context
- Link to PA decisions (FHIR PAS/278), medical policies, clinical notes, and required attachments (LOINC‑coded, X12 275/FHIR Attachments) to prevent avoidable denials.
- Pricing and adjudication
- Contract and fee‑schedule pricing (DRG/APC/ASC, RVU, percent‑of‑charge), multiple procedure discounting, bundling/unbundling edits, NCCI, MUE, global periods, modifiers, place‑of‑service, and benefit accumulations (deductible/coinsurance/copay).
- Payment‑integrity and risk controls
- Prepay edits, duplicate and near‑duplicate detection, DRG/APC validation, clinical validation, surprise billing/NSA compliance, COB/subrogation scoring, and post‑pay audit workflows.
- Decisioning and explanation
- Determinations with EOB/EOP reason codes (CARC/RARC), provider/member‑friendly narratives, and appeal/redo routes—exportable as 835 remittances.
- Payment and reconciliation
- EFT/ERA (835/CCD+/NACHA), virtual card options, payment scheduling, recoupments, interest where mandated, and ledgering/recon.
- Analytics and feedback
- STP rate, denial taxonomy, rework loops, provider scorecards, leakage by edit, turnaround times, and “claims receipts.”
- Data and interoperability foundations
- Dual rails: EDI + FHIR
- Maintain full X12 fidelity while projecting claims to FHIR for APIs, analytics, and prior‑auth/clinical linkages; support bulk Flat FHIR NDJSON exports.
- Terminologies and reference data
- ICD‑10‑CM/PCS, CPT/HCPCS, NDC, LOINC, SNOMED CT, DRG/APC groupers, POS/TOB, provider NPI/Tax IDs, and contract reference tables—versioned with effective dates.
- Provider identity and contracting
- Credentialing data, directory sync, taxonomy/specialty, contracted rates and carve‑outs; detect out‑of‑network with NSA workflows (AEOB, IDR support).
- Automation levers that move STP and reduce abrasion
- Smart validation and edits
- Real‑time front‑end edits for common errors (member ID, eligibility dates, gender/age conflicts, diagnosis‑procedure mismatches) with provider‑portal hints; reduce back‑and‑forth.
- Context‑aware pricing
- Auto‑select correct fee schedule by contract, date of service, site of care, and modifier stack; support multi‑line bundling and bilateral surgeries correctly.
- Attachments automation
- NLP and vision extract required elements from clinical docs, op notes, imaging; request missing attachments with precise checklists; auto‑link to claim/line items.
- COB and subrogation
- External data and rules to find primary coverage events (workers’ comp, auto, liability), accident indicators, and recovery opportunities; route to specialized queues only when high‑confidence.
- NLP for explanations
- Generate plain‑language EOB excerpts mapped to CARC/RARC; reduce provider calls and member confusion.
- Payment integrity and FWA (fraud, waste, abuse)
- Prepay layers
- Code pair edits (NCCI), upcoding/outlier detection (DRG shifts, high RVU clusters), frequency/quantity checks, unbundling and mutually exclusive procedures, place‑of‑service anomalies.
- Post‑pay and SIU
- Provider peer grouping, billing pattern anomalies, network leakage, ghost billing; graph analytics across members, providers, pharmacies, and devices.
- Pharmacy and DME nuances
- NDC units conversion, refill too soon, DAW logic, PA step therapy; DME capped rental vs. purchase, same/similar, lifetime limits.
- Governance
- Reason codes with evidence snapshots; configurable tolerance thresholds; track yield and provider abrasion metrics to tune programs.
- Provider experience: portals and APIs that prevent rework
- Self‑service and updates
- Claim status (276/277 or FHIR), correction and resubmission flows, attachment upload, appeal/grievance submission, and chat/secure messaging; clear SLAs.
- Estimation and AEOB
- Real‑time cost estimates and Advanced EOB for scheduled services where required; member‑facing clarity.
- Bulk and developer experience
- Batch uploads, status webhooks, sandbox with seeded claims and failure cases; versioned APIs; uptime and incident status pages.
- Security, privacy, and sovereignty by design
- Identity and access
- SSO/MFA/passkeys for staff and providers; RBAC/ABAC with least privilege; break‑glass with multi‑party approval; session recording on sensitive consoles.
- Data protection
- Encryption at rest/in transit, field‑level protections for PHI, tokens for identifiers; region pinning, BYOK/HYOK for regulated clients; private networking.
- Compliance
- HIPAA/HITECH, 42 CFR Part 2 segmentation for SUD data, SOC2/ISO attestations; audit trails, retention schedules, legal holds; vendor SBOMs and signed builds.
- Lawful access and auditability
- Immutable logs, decision traces, model cards for AI, change control for rules/contracts; downloadable evidence packs.
- AI that helps—governed end‑to‑end
- Assistive copilots
- Summarize claims and policies for adjudicators; draft appeal responses with citations; highlight likely reversible denials.
- Classification and extraction
- Auto‑classify claim types and route to specialized queues; extract key fields from clinical attachments and map to codes.
- Risk and integrity models
- Predict overpayment risk, duplicate likelihood, DRG validation flags; champion‑challenger with monotonic constraints where needed.
- Guardrails
- Tenant‑scoped retrieval; no training on PHI without explicit opt‑in; human approval for payment changes; full prompt/tool logs and cost budgets.
- Architecture and reliability
- Event‑driven spine
- Events for claim.received → validated → priced → adjudicated → paid/denied → adjusted; idempotent processors; dead‑letter and replay for audits.
- Performance and SRE
- Parallelize adjudication by claim/line; p95/p99 latency targets for status/APIs; auto‑scaling with budgets; chaos drills for partner outages (clearinghouses, banks).
- Business continuity
- Immutable backups, multi‑AZ/region, runbooks for payer/provider link failures; fallback to batch when needed with reconciliation.
- Pricing and packaging patterns
- SKUs
- EDI/FHIR Connectivity, Validation & Edits, Pricing & Contracts, Adjudication & EOB, Attachments & Prior‑Auth Link, Payment Integrity (Prepay/Post‑pay), FWA/SIU Analytics, Provider Portal & APIs, Payments & Reconciliation, Enterprise Controls (BYOK/residency, private networking, premium SLA).
- Meters
- Claims ingested/adjudicated, lines processed, attachments handled, PA links, integrity checks run, models minutes, API calls, storage/retention; pooled credits with budgets and soft caps.
- Services
- Contract/fee schedule onboarding, policy/rules configuration, NCCI/medical policy mapping, provider enablement, data migration, audit/readiness packs.
- KPIs and “claims receipts”
- Speed and experience
- STP rate, median adjudication time, provider inquiry rate, appeal overturn rate, days to pay, attachment turnaround.
- Quality and leakage
- Overpayment prevention yield, duplicate/near‑duplicate catch, payment accuracy rate, denial preventability %, FWA recoveries.
- Operations
- First‑pass clean claim %, rework rate, cost per claim, backlog days, rule/model rollback frequency and MTT‑rollback.
- Compliance and trust
- Audit findings closed, PHI incident minutes (target zero), Part‑2 segmentation accuracy, provider portal uptime, transparency of EOB narratives.
- 30–60–90 day rollout blueprint
- Days 0–30: Connect clearinghouse/EDI, validate 837 → 999/277CA flows; stand up canonical model and FHIR projection; enable core edits and eligibility (270/271); configure 1–2 fee schedules; enforce SSO/MFA and audit logs; define “claims receipts.”
- Days 31–60: Turn on pricing/adjudication with CARC/RARC mapping; add attachments (X12 275/FHIR) and link to prior auth; enable provider portal for status and corrections; launch prepay integrity rules (duplicates, NCCI); stand up EFT/ERA test payments.
- Days 61–90: Expand contracts (DRG/APC) and benefit accumulators; introduce FWA risk flags and post‑pay audit queues; ship member‑friendly EOB narratives; publish first receipts (STP↑, days‑to‑pay↓, overpayment yield↑) and finalize BYOK/residency options.
- Common pitfalls (and fixes)
- Black‑box rules and denials
- Fix: expose reason codes + narratives, publish policy references, and provide easy correction/appeal flows; monitor overturns and tune.
- Contract chaos and version drift
- Fix: versioned fee schedules with effective dates and audits; test suites covering modifiers and bundles; change‑control gates.
- Attachments bottlenecks
- Fix: early, precise requests; NLP extraction and validation; SLAs and reminders; escalate only high‑impact misses.
- Integrity vs. abrasion trade‑offs
- Fix: segment providers, tune thresholds, and measure call/appeal load; blend pre‑ and post‑pay for contentious edits.
- Privacy and Part‑2 gaps
- Fix: segment sensitive data, purpose tags and masking, role‑scoped access, and logs; regular audits and drills.
Executive takeaways
- A SaaS control plane can make claims flow straight‑through, priced correctly, and explained clearly—reducing admin cost, leakage, and provider/member friction.
- Unify EDI and FHIR, codify pricing and medical policies with transparent reason codes, automate attachments and PA context, and layer pre‑/post‑pay integrity and FWA analytics.
- In 90 days, payers can light up clean intake, baseline adjudication, attachments, and provider self‑service—then scale to advanced pricing, integrity analytics, and sovereign controls—publishing “claims receipts” that show faster pay, fewer denials, and measurable savings.