Enabling High Quality, Effective Transaction Management

Studiomaca Payer Connectivity Services (PCS) is an editing and routing gateway that allows a payer to consolidate and manage inbound and outbound EDI transaction streams at a single connection point. This is all accomplished using a flexible and scalable SaaS platform. The single connection point sits between submitters (regardless of how many you have) and your adjudication system, enabling payers to:

 CAQH Certification
  • Increase first pass adjudication rate substantially by using advanced custom edits and standard WEDI SNIP edits
  • Simplify the claims administration process by managing a single transaction stream from multiple submitters
  • Reduce provider relations expenses with portal research functions and metrics to proactively reduce common provider errors
  • Perform analysis for multiple submitters via a single portal
  • Route transactions to the appropriate processing path (even with multiple claim systems and lines of business) based on custom transaction routing
  • Support regulatory compliance (CORE Phase I, II, III and HIPAA 5010 compliant)
  • Support all standard HIPAA transactions (837, 835, 270/271, 276/277/277CA, 278, 820, 834, 835, 999/TA1)

The potential for administrative waste across a health plan’s claims, operations, network management, and EDI departments stems from a variety of sources. Whether it’s low first-pass rates, claim rework due to incorrect routing, multiple adjudication systems clogging up claims traffic, routing expenses for multiple clearing house connections, unpredictable transaction costs or fines due to non-compliance with regulations, each roadblock can potentially increase the complexity as well as the potential for error and rework.

PCS Workflow

Improving administrative efficiency can be the key to your health plan’s success. A single transaction workflow solution helps enable industry standard and payer-specific business rules and compliance with legislative mandates.

Studiomaca Payer Connectivity Services help:

  • Increase first-pass adjudication. By catching errors up-front in processing with the application of advanced claims edits and presenting edit errors directly to submitters, claims can be made cleaner when routed for processing.
  • Support regulatory compliance. Comply with federal regulations and help achieve compliance with CORE Phase I, II and III for ACA Operating Rules. PCS is also HIPAA 5010 compliant.
  • Simplify the claims administration process. Consolidate submitters and reduce administrative complexity so it’s easier for providers and payers to work together.
  • Improve claims routing accuracy and reduce claim rework. With the ability to route transaction data to the appropriate processing path, you can simplify any transactional workflow—even one with multiple claims systems and lines of business.