Healthcare EDI In Action

Small and mid-size practices use edifunctions to submit professional claims, verify patient eligibility in real-time, and process electronic remittance advice — all integrated with their PMS.

• CMS-1500 PDF → 837P conversion & submission
• Real-time eligibility checks (270/271) before visits
• ERA/835 auto-posting to practice management
• Claim status inquiries (276/277) on demand
• Multi-payer clearinghouse connectivity
• OCR for paper CMS-1500 scanning

Large hospitals and health systems use edifunctions for high-volume institutional claims, automated remittance reconciliation, and deep EHR integration across multiple departments.

• UB-04 → 837I institutional claim submission
• High-volume batch processing (10,000+ claims/day)
• Multi-facility billing consolidation
• EHR/EMR integration (Epic, Cerner, Meditech)
• Automated denial management workflows
• Prior authorization automation (278)

Dental practices use edifunctions to submit dental claims electronically, verify insurance coverage, and process payments — replacing manual paper-based workflows.

• ADA form → 837D electronic claim submission
• Dental eligibility verification before treatment
• CDT code validation & compliance
• ERA/835 payment reconciliation
• Direct payer connectivity for major dental insurers
• Integration with Dentrix, Eaglesoft, Open Dental

Healthcare organizations use edifunctions to connect with clearinghouses for claim scrubbing, submission routing, and response retrieval across multiple payers.

• Availity, Change Healthcare, Trizetto connectivity
• Office Ally, Waystar, Relay Health support
• Multi-clearinghouse routing rules
• Claim scrubbing before submission
• Automated response retrieval (997/999, 277)
• SFTP, AS2, and HTTPS connectivity

Software vendors embed edifunctions SDK directly into their PMS, EMR, or billing applications to offer built-in EDI capabilities to their customers.

• .NET SDK integration (NuGet)
• White-label EDI processing
• Multi-tenant architecture support
• API-first integration
• Custom branding & workflows
• Per-customer EDI configuration

Third-party billing companies use edifunctions to manage EDI for multiple provider clients, automating claims, payments, and reporting across practices.

• Multi-provider claim management
• Centralized clearinghouse connectivity
• Batch claim submission & tracking
• ERA/835 splitting by provider
• Denial analytics & reporting
• Client-specific payer routing

Health insurance payers use edifunctions to receive and process claims, generate remittance advice, handle eligibility inquiries, and manage member enrollment.

• Inbound 837 claim ingestion & parsing
• 835 remittance advice generation
• 271 eligibility response automation
• 834 member enrollment processing
• Provider credentialing workflows
• Premium payment (820) processing

Government healthcare programs use edifunctions for Medicare/Medicaid claim processing, beneficiary enrollment, and regulatory compliance reporting.

• Medicare Part A/B claim submission
• Medicaid state-specific companion guides
• Beneficiary enrollment (834)
• HIPAA 5010 strict compliance
• Audit trail & compliance reporting
• Air-gapped on-premise deployment