We build HIPAA-compliant, AI-powered health insurance platforms that handle claims adjudication, enrollment, member portals, prior authorization, and provider network management. Built for regulated payer environments - from regional health plans to Medicare Advantage.
HIPAA Compliant
HL7 / FHIR Compatible
SOC 2 Type II
Trusted by industry leaders
Certifications and Accreditations
From core administration systems to AI-driven adjudication engines, we develop production-grade insurance software tailored to the operational complexity of regulated payer environments. Every build starts with compliance architecture, not as an afterthought.
We architect and build core administration systems that manage the full policy lifecycle from quoting and enrollment through billing, claims processing, and renewals. Designed for long-term scalability and CMS interoperability compliance.
Custom enrollment solutions that handle ACA marketplace integration, employer group management, COBRA administration, subsidy and premium tax credit logic, and EDI 834 transaction processing for plan sponsors and TPAs.
Automated claims adjudication engines with rule-based validation, coordination of benefits COB logic, duplicate detection, and remittance processing via EDI 837 and 835. Designed to reduce manual review queues and adjudication cycle time.
We build prior authorization workflows compliant with the CMS-0057-F Prior Authorization API mandate, including FHIR-based payer-to-payer API connections, real-time PA decision engines, and integrations with UM vendors and EHR systems.
Secure, responsive portals that give members real-time access to benefits, claims status, EOBs, and plan documents, and give providers direct access to eligibility verification, claim submission, and remittance history.
ML models trained on claims history and provider behavior patterns to flag anomalies, identify billing irregularities, and surface high-risk claims before payment. Supports underwriting risk stratification and HCC coding accuracy for Medicare Advantage plans.
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Data engineering and analytics platforms that aggregate claims, clinical, and pharmacy data to support actuarial modeling, HEDIS measure reporting, risk score calculation, and value-based care payment reconciliation.
Automated premium billing, invoicing, and multi-channel payment collection for individual, group, and government-sponsored plans. Includes grace period management, lapse processing, and integration with payment gateways and lockbox providers.
We turn your requirements into production-ready systems with the right architecture, integrations, and compliance built in.
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Claims adjudication involves thousands of rule intersections across benefit configuration, eligibility at date of service, coordination of benefits, subrogation, network status, and fee schedules. A single claim can trigger dozens of logic paths, directly impacting denial rates, costs, and member experience.
Enrollment must support SEP logic, APTC reconciliation, employer eligibility, COBRA continuation, and EDI 834 exchanges with CMS and employers. All of this must work alongside retroactive eligibility tracking, where small data errors often surface later as costly claims denials.
CMS-0057-F requires most payers to implement FHIR R4 Prior Authorization APIs by January 2026, with strict response timelines. Payers without modern infrastructure risk non-compliance, operational strain, and increasing provider dissatisfaction due to delays and lack of real-time visibility.
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COB logic determines primary coverage, applies secondary payer payments, and prevents duplicate reimbursement. Errors create overpayment risk and reconciliation challenges. At scale, this requires a purpose-built rules engine capable of handling high-volume claims with consistent, accurate decision logic.
Look for platforms that support rule-based validation, smart routing, and automated adjudication. This reduces manual work, speeds up reviews, and improves accuracy across the entire claims lifecycle.
Your system should allow quick updates to plan benefits, coverage limits, eligibility rules, and pricing without heavy development effort. This flexibility ensures faster adaptation to regulatory or market changes.
The modern health insurance software must contain AI models to identify anomalies, notice suspicious patterns, and conduct automatic analysis of documents. This assists the insurers in minimizing the losses and enhancing risk management.
Automated premium billing, invoicing, reminders, and multi-method payment options are used to simplify financial operations and enhance payment accuracy across individual and group policies.
Health insurance platforms should support secure EDI transactions, enabling seamless communication with clearinghouses, providers, and partners for claims, eligibility checks, and remittance advice.
An encrypted centralized storage is used to maintain all policy, claims, and compliance records in a well-organized and accessible manner. This improves traceability and supports regulatory audits.
Real-time clinical data exchange with Epic, Cerner, Oracle Health, and athenahealth via FHIR R4 APIs
CDS Hooks integration for point-of-care prior authorization decision support
SMART on FHIR application launch for member and provider-facing tools
Patient demographic and coverage verification at time of service
EDI 837P and 837I for professional and institutional claim submission
EDI 835 Electronic Remittance Advice with automated payment posting
EDI 270/271 real-time eligibility inquiry and response
EDI 834 benefit enrollment and maintenance with employer groups and CMS
EDI 277 claim acknowledgment and status
Direct connectivity to Change Healthcare, Availity, Waystar, and Trizetto
Claim scrubbing and validation before submission to reduce rejection rates
Real-time claim status tracking and denial reason categorization
Remittance aggregation and reconciliation across payer portals
Real-time formulary and drug tier lookup for member-facing tools
Prior authorization status exchange with Express Scripts, CVS Caremark, and OptumRx
Medication adherence data integration for population health platforms
NCPDP transaction support for pharmacy claims and eligibility
CMS FFM and SBM enrollment and reporting APIs for marketplace plans
Medicare Advantage encounter data submission to RAPS and EDPS
HHS Risk Adjustment Data Validation (RADV) audit preparation data flows
Medicaid and CHIP T-MSIS encounter data and eligibility file processing
Premium collection via ACH, credit card, and lockbox with automatic reconciliation
ERA and EFT enrollment and remittance processing through CAQH EnrollHub
Capitation payment calculation and distribution for value-based contracts
Financial reporting integration with ERP systems such as SAP, Oracle, and Workday
Development costs range from $20,000 for focused modules (member portal, enrollment system) to $100,000+ for a full payer platform with claims adjudication, prior authorization, and CMS interoperability APIs. Share your requirements for an accurate estimate.
All ePHI must be secured at rest and in transit using AES 256 encryption, access controls, and audit logging. Our platforms are built for HIPAA Security Rule compliance from the start, with breach workflows and BAA management included.
Exchange plans must support FFM and SBM connectivity, handle APTC and CSR reconciliation, and transmit daily 834 files. We build and maintain these integrations and support high volume processing during SEP and OEP periods.
Requires transparent out-of-network cost estimates, IDR workflows, and good faith estimates. We embed NSA-compliant logic into prior authorization and claims systems to reduce compliance risk and avoid penalties.
Effective January 2026, mandates FHIR R4 APIs for prior authorization, patient access, provider directories, and payer data exchange. We implement Da Vinci aligned APIs and help close compliance gaps.
Plans pursuing NCQA accreditation must generate HEDIS data from claims and clinical systems. We build pipelines that extract, structure, and prepare encounter data for accurate reporting and submission.
Health insurance platforms fail when compliance, integration, and claims logic are treated as phases rather than foundations. We structure every engagement so that the hard problems are solved before development begins, not during user acceptance testing.
We map benefit plans, claims workflows, integrations, and regulatory obligations, delivering a compliance architecture, integration inventory, and data model upfront to prevent costly mid-build surprises in payer IT projects.
Architects define adjudication engines, EDI flows, FHIR APIs, and member and provider data models, documenting decisions against HIPAA, ACA, and CMS-0057-F so compliance remains auditable from day one.
Engineers build in agile sprints with working software reviewed every two to four weeks, while EDI integrations, FHIR endpoints, and clearinghouse connections are developed and tested alongside core applications.
We perform HIPAA transaction testing, FHIR conformance validation, and claims scenario testing across benefit plans, alongside penetration testing and vulnerability assessments to ensure compliance and security before go-live.
We deploy to HIPAA-compliant cloud environments, manage cutover with your operations team, and provide ongoing support with SLAs for production issues, remaining engaged beyond go-live for long-term stability.
Insurance software decisions carry multi-year consequences. The right partner needs more than development capability. They need regulatory fluency, integration depth, and the operational discipline to deliver in a compliance-controlled environment.
Our engineers hold working knowledge of HIPAA EDI transaction sets, FHIR Implementation Guides, ACA marketplace requirements, and CMS regulatory timelines. Compliance is not handled by a QA checklist. It is built into architecture from the first design session.
We do not use off-the-shelf middleware connectors that create vendor lock-in and limit your control. Our EDI processors, FHIR endpoints, and clearinghouse integrations are built to the published standard, giving you source-code ownership and long-term flexibility.
Our ML models for fraud detection, risk stratification, and adjudication automation are developed with explainability in mind. Insurers operating in regulated environments need models whose decisions can be documented and defended, not black boxes.
Our ISO 27001 certification reflects a managed security program, not just secure coding practices. Encryption at rest and in transit, role-based access control, audit logging, and vulnerability management are standard on every health insurance engagement.
Health insurance platforms are too complex for junior developers to learn on your project. Your engagement is staffed with senior engineers who have delivered claims, enrollment, and compliance-critical systems before.
You own everything we build. No license fees, no vendor lock-in, no proprietary platforms. The code, documentation, and infrastructure configurations are transferred to you at project completion.
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Read Article →It is the design and development of software that supports payer operations such as claims adjudication, enrollment, prior authorization, provider network management, billing, and reporting. Unlike general healthcare IT, it focuses on administrative and financial workflows rather than clinical care delivery.
At minimum, software must comply with HIPAA, HITECH, and ACA requirements. Additional rules include CMS-0057-F (APIs and prior auth), the No Surprises Act, and NCQA standards. Systems must also meet HIPAA Security Rule safeguards like encryption, audit controls, and access management.
CMS-0057-F is a CMS interoperability and prior authorization rule effective January 1, 2026. It requires FHIR R4 APIs for patient access, prior auth, provider directory, and payer data exchange. It applies to Medicare Advantage, Medicaid, CHIP, and marketplace plans, with compliance risks if unmet.
A single module (e.g., portal or prior auth workflow) typically takes 4–6 months. A full payer platform can take 12–24 months depending on complexity. Initial discovery and compliance architecture take about 4–6 weeks and help avoid delays later.
Yes. Integrations with systems like Epic, Oracle Health (Cerner), and athenahealth are built using FHIR APIs and SMART on FHIR. We also implement CDS Hooks for prior auth workflows and support EDI transactions like eligibility checks and clinical data exchange.
Claims management systems track and store claims, while adjudication systems make payment decisions based on eligibility, benefits, contracts, and policies. Adjudication engines are complex and often custom-built to give payers full control over rules and logic.
AI improves fraud detection, prior authorization, and risk stratification. It helps identify suspicious claims, automate clinical review using NLP, and predict high-risk members for care management, improving efficiency and quality outcomes.
When it comes to finding a trustworthy insurance software development firm, research their past insurance software projects, their capability of creating secure and compliant software, their technical capabilities, their reviews on Clutch and Good Firms, and their transparency throughout the project and post-launch support.
