ClaimSync EDI
Two systems that should already be talking.
ClaimSync establishes automated, bi-directional data exchange between your claims management system and your medical bill review platform — using scheduled jobs and secure SFTP transfers, with roughly 95% fewer data-entry errors than manual re-keying.
The problem
Disconnected systems cost more than they look like they do.
Managing claims data across systems that don't talk creates:
- Data fragmentation across multiple platforms
- Manual re-entry, which produces errors and inconsistencies
- Delayed claims processing and payment cycles
- Limited visibility into the complete claims lifecycle
- Compliance risk from incomplete or outdated data
None of these show up as a line item. They show up as cycle time, rework, and an examiner asking a colleague to check a number that should have arrived correct.
Platform capabilities
What ClaimSync does.
Automated job scheduling
Transfers run on a schedule and complete overnight, so examiners have work waiting in the morning rather than a queue that needs someone to press a button.
Secure SFTP transfer
HIPAA-compliant transmission protocols and encryption standards protect data in transit between systems.
Custom-built integrations
Built to your data, your formats, and your business rules. Standard EDI transaction formats and custom mappings are both supported.
Bi-directional flow
Data moves both ways, so the claims system and the bill review platform stay current with each other instead of drifting.
Web API integration
Where the connected systems support it, we integrate over API rather than files.
Works with legacy systems
Proprietary in-house claims systems, TPA platforms, commercial RMIS, and older systems that need modernizing without being replaced.
Data exchange
What moves, and which way.
InboundClaims management → bill review
- Claims data
- Claimant information, dates of loss, injury descriptions, claim status, and jurisdictional data
- Provider information
- Provider demographics, NPI numbers, tax IDs, specialties, addresses, and contact information
- Adjuster data
- Adjuster assignments, contact details, authorization levels, and case management information
- Legal representatives
- Attorney information, law firm details, representation dates, and communication preferences
- Jurisdictional data
- State-specific requirements, fee schedules, regulatory information, and compliance data
OutboundBill review → claims management
- Payment recommendations
- Adjudicated bill amounts, recommended payment values, savings calculations, and approval status
- Explanation of Review
- Detailed adjudication reports, line-item analysis, savings breakdown, and compliance notes
- Bill images
- Original scanned bills, supporting documentation, and processed images linked to claim records
- Payment processing
- Integration with payment services for automated check printing, EFT, and payment tracking
Claims management systems
- Proprietary in-house claims systems
- Third-party administrator (TPA) platforms
- Commercial RMIS and policy administration systems
- Legacy claims systems requiring modernization
Bill review systems
- Enlyte SmartAdvisor®
- CompIQ
- Prime Renovo
- Startacare
- Other medical bill review platforms
What are your systems still not sharing?
Tell us which platforms you run on each side and we'll tell you what an integration looks like.