HIPAAsuite Adjudication replicates the exact pricing algorithms CMS uses for Medicare, Medicaid, and commercial plans — available to health plans, government payers, and TPAs of any size, without the enterprise price tag.
Enterprise claim systems cost millions and take years to implement. Smaller payers are left with manual spreadsheets, outdated fee tables, and adjudication errors that erode margins and invite audit risk.
We built the adjudication engine that regional payers, county health departments, and self-insured employers actually need — the same fee-schedule logic CMS runs, packaged for organizations that process thousands of claims a month, not millions.
No feature is gated behind a higher tier. Every capability ships in a single, fully configured platform.
We didn't license a black-box grouper or wrap CMS's COBOL binary. We re-implemented the complete 8-step CMS MS-DRG algorithm in native C# — fed by the same nine reference tables CMS publishes in the annual IPPS Final Rule: Pre-MDC bypass for transplants and ECMO, principal diagnosis → MDC assignment, surgical/medical partition via ICD-10-PCS OR procedure detection, CC/MCC severity scoring, CC exclusion pairs (Appendix B), Hospital-Acquired Condition / POA exclusions, procedure-specific and diagnosis-specific DRG resolution, severity-sibling matching, and relative weight lookup. Every grouping decision is written to a logged decision trail — step by step, code by code.
Claims flow from receipt to adjudicated status without manual intervention. Configurable rules engine handles edits, medical necessity, duplicate detection, and re-adjudication on plan changes.
Produces HIPAA 5010 X12 835 remittance advice files that pass SNIP 1–3 validation. CLP, SVC, CAS, and PLB segments generated automatically with full CMS-spec adjustment reason codes.
Every payment file is accompanied by a NACHA-compliant CCD+ ACH file for direct provider payment. File header, batch, entry detail, and addenda records all built to spec — ABA check digits verified, blocks padded correctly.
Assign separate fee schedule families per provider — Primary, Hospital, Ancillary 1–3. Each family can hold a different fee schedule version, allowing plan-specific pricing without duplicating provider records.
Every adjudication decision is written to the decision trail table with a timestamp, applied rule, before/after amounts, and reason codes. Pull a complete audit record for any claim in seconds.
Handles both UB-04 (837I) and CMS-1500 (837P) claim types in the same platform. DRG-based institutional payment, line-item professional adjudication, and ancillary service pricing all co-exist.
Configure payers, clearinghouses, and banking partners as trading partners with per-partner EDI settings, outbox directories, filename schemes, and transmission profiles — including VAN, FTP, and AS2.
Run a Medicaid plan and a commercial PPO on the same platform simultaneously. Plan-specific benefit rules, member eligibility, and fee schedule assignments are maintained independently per plan.
If you process 500 or 500,000 claims a month, you deserve fee-schedule accuracy. HIPAAsuite was designed from the ground up for organizations that need enterprise precision without enterprise complexity.
County health departments, municipal employee health plans, and CHIP administrators operating under state Medicaid rules.
TPAs managing self-insured employer plans who need accurate claim adjudication and provider payment without building in-house IT.
Companies with 200+ employees self-funding their health benefit who want to stop overpaying on inpatient and professional claims.
Small and mid-size health plans serving rural or underserved markets where enterprise vendor pricing is prohibitive.
State funds and private carriers processing occupational injury claims against state-mandated fee schedules and OMFS guidelines.
638 tribal health programs, Indian Health Service contractors, and tribal self-governance plans serving Native American communities.
No black boxes. Every step is configurable, every decision is logged, and every output is a HIPAA-compliant file your providers and banking partners already know how to receive.
837I / 837P EDI files loaded directly or imported from your clearinghouse. Paper claims entered via data entry screen.
Institutional claims run through the full MS-DRG grouper — ICD-10 codes in, DRG assigned. Professional claims price against RBRVS. Zero manual touches.
Reviewers see adjudicated amounts, adjustment reasons, and provider-level payment totals in one screen before approving.
One click generates the HIPAA 835 remittance and the NACHA CCD+ ACH file. Both land in your outbox and transmit to trading partners.
We don't approximate the standards — we implement them character by character, then validate against them before anything leaves the system.
CMS publishes the MS-DRG grouper as a set of COBOL programs and nine annual reference tables. Most vendors license a third-party binary and call it a day. We studied those tables and built the full algorithm ourselves in C# — every step documented, every decision logged, every edge case handled: Pre-MDC bypass, MDC routing, surgical partition, CC/MCC scoring, CC exclusion pairs, HAC/POA rules, and DRG selection with severity-sibling resolution.
When CMS publishes updated IPPS Final Rule tables each October, you import the new reference data. The grouper runs against the correct fiscal-year tables for each claim's date of service automatically.
Every percentage point of overpayment you stop is revenue back in your reserve. For a payer processing $10M in annual claims, the numbers are hard to ignore.
"We were paying billed charges on inpatient claims because we had no DRG engine. HIPAAsuite's MS-DRG adjudication cut our average inpatient payment by 34% in the first quarter — while still paying providers fairly."
"As a TPA, we manage 14 self-insured employer clients. HIPAAsuite lets us run separate fee schedules per client on one platform. The 835 files it generates pass every clearinghouse edit without a single rejection."
"State Medicaid auditors asked for a full adjudication decision trail for 200 claims. We pulled it in under five minutes. Every rule, every rate, every adjustment reason — all there. The audit closed with zero findings."
Bring five of your most complex claims. We'll run them through the adjudication engine live, generate the 835 and CCD+, and show you exactly what you're leaving on the table today. No slide decks. No sales pitch. Just your claims, adjudicated correctly.
No commitment. No CRM spam. Typically scheduled within 48 hours.
Healthcare and ACH payment standards are dense with acronyms. Hover over any highlighted term on this page for a quick definition, or browse the full glossary below.