Core services facilitate secure ubiquitous connectivity, interactive and batch transaction support, Web portal integration, trading partner management, and provide pre-adjudication processing for healthcare transactions and browser-based interactions.

EDI Gateway

The EDI gateway services support the exchange of electronic batch or real-time transactions, in virtually any format, and between any payor and provider.

Portal Services

HeC integrates with portals to support Web interactions between payors, providers, and trading partners.  Web transactions supported include:

HeC has established connectivity with many of the major clearinghouses in the country.  Let HeC aggregate all your electronic transactions and submit the data to you in one consistent format.  You’ll only need to establish one trading partner and implement one EDI connection for both your paper and electronic claims.

HIPAA EDI and Security Compliance

HeC and HeC trading partners provide HIPAA compliant EDI and Security services.

Solutions that meet HIPAA security requirements for electronic communications must support two basic requirements, authentication to confirm the identity of the trading partner, and encryption to encode the data.

Two methods of authentication are used to authorize electronic access:

1.   User ID and password – used primarily for Web-based interactions.

2.    Digital certificates – used when exchanging X12 transactions with other systems.

Encryption techniques include 128-bit Secure Sockets Layer (SSL) when using Hyper Text Transfer Protocol (HTTP) as the transport protocol, and Pretty Good Privacy (PGP) 1024-bit encryption when using File Transfer Protocol (FTP) for the transport protocol.

Claim Validation

HeC’s comprehensive claim validation services include eligibility verification, the use of industry standard and customer specific rules-based edits, PPO repricing, and claim repair service options.  These pre-adjudication functions simplify PPO management and dramatically increase transaction processing first-pass rates, and in turn improve efficiency, reduce processing costs, and improve customer service levels.  Claim validation services are performed on claims arriving as paper forms and electronic transactions.

Eligibility

During the claim validation process, member eligibility is verified and proper PPO routing is determined. HeC also accommodates and processes single or batch mode ANSI standard 270 eligibility inquiry transactions, and returns an ANSI 271 or XML response. 

Rules-Based Edits

Using a knowledge base of customer specified and industry standard rules, HeC’s configurable claim editing software validates each claim to eliminate or flag errors prior to adjudication.  Claims with missing or incorrect information can be selectively returned to the source.

PPO Repricing

HeC has direct connections with over 40 Preferred Provider Organizations (PPOs), including the largest national PPOs.  HeC can route claims that originated as paper forms or electronic transactions to the appropriate PPO.  The PPO reprices the claim and sends either directly to the payor or back to HeC for further processing.  HeC’s Out-of-Network Control Services will also manage your out-of-network repricing, fee negotiations, hospital U&C, and more.

Claims Repair Shop

Based on payor specific edits, claims will be rejected during the validation process. HeC’s Claims Repair Shop allows you to return rejected claims to the provider for correction and resubmission, or the provider can correct the claim online. Claims can be returned to the provider via fax, mail, or electronically.