EHR to billing to clearinghouse to payer
We connect your EHR or practice management system, your billing platform and your clearinghouse so every encounter becomes a checked claim, every response finds its way back to the right record, and every payment posts against the claim it paid. Eligibility, claims, status, remittance and denials, engineered as one loop.
270 out, 271 back before the visit, benefits mapped to the registration screen.
Charges, ICD-10-CM and CPT or HCPCS from the EHR into an 837, scrubbed before release.
999 and 277CA tied to the claim, rejections routed for correction.
276 inquiries on an aging schedule, 277 answers on the claim record.
835 payments and CAS adjustments matched to claim lines, exceptions queued.
The short answer
RCM integration connects the clinical side of care to the money side. We build the interfaces between your EHR or practice management system, your billing or RCM platform, your clearinghouse and, where it pays off, payers directly. That means the X12 transactions (270/271 eligibility, 837 claims, 999 and 277CA acknowledgements, 276/277 status, 835 remittance), the mapping from encounter to claim, and the return path that puts every response back on the record it belongs to. You get fewer claims lost between systems, denials that arrive with their reason attached, and remittance that reconciles to the cent.
RCM transactions
Every step of the revenue cycle has a HIPAA-adopted X12 transaction behind it. These are the version 5010 transactions your clearinghouse and payers will expect, and the part of each one that usually breaks.
| Workflow | Transactions | What moves | What we design for |
|---|---|---|---|
| Eligibility and benefits | 270 request, 271 response (005010X279A1) | Coverage status, plan, copay, coinsurance, deductible and limits per service type | Service type codes, AAA rejections, and turning EB segments into something a front desk can read in seconds |
| Claims | 837P professional, 837I institutional, 837D dental | Billing, rendering, referring and supervising providers, ICD-10-CM diagnoses, CPT and HCPCS lines, modifiers | Provider loops (NM1*85, 82, DN, DQ), taxonomy, frequency codes for corrected and void claims |
| Acknowledgements | TA1, 999, 277CA | Interchange, syntax and front-end claim acceptance or rejection | Correlating each acknowledgement to the batch and claim, and never treating a 999 accept as payer acceptance |
| Claim status | 276 inquiry, 277 response (005010X212) | Status category and status codes per claim | An aging poll loop, because payer status does not arrive unless you ask for it |
| Remittance | 835 (005010X221A1) | Payments, CAS adjustments by group code, CARC and RARC reasons, PLB provider-level adjustments | Claim-line matching, partial payments, reversals, and posting rules agreed with the billing team |
| Prior authorization | 278 request and response; FHIR PAS under CMS-0057-F | Service review requests and decisions | Which payers support 278 at all, and the FHIR Prior Authorization API impacted payers must run from January 2027 |
| Enrollment and premium | 834 benefit enrollment, 820 premium payment | Member enrollment and payment data between sponsors and plans | Full versus change files, and effective-dated member history |
Operating rules from CAQH CORE sit on top of these transactions: for example, a real-time 271 must come back within 20 seconds, and 835 and EFT enrollment follow a standard data set.
What we build
Each workstream ships with a specification, tests and an owner. Most engagements start with the one that is costing you the most.
Encounters, charges, diagnoses and provider data from the EHR into your billing or RCM platform, through FHIR APIs, HL7 DFT^P03 feeds or database extracts, with every source identifier kept.
FHIR Claim and Encounter · HL7 DFT^P03 · ICD-10-CM · CPT · HCPCS
EHR and EMR integration services →Real-time 270/271 at scheduling and check-in, batch eligibility for tomorrow's schedule, and benefit responses parsed into copay, deductible and coverage flags your staff can act on.
270/271 005010X279A1 · CAQH CORE · EB and AAA segments
Automating 270/271 eligibility →837P, 837I or 837D generated from source data, validated against the implementation guide, payer companion guides and your own edits before release, so rejections are caught in-house.
837P · 837I · 837D · NCCI edits · companion guides
Clearinghouse integration in production →TA1, 999 and 277CA correlated back to batches and claims, plus a 276 polling schedule that keeps payer status current instead of stale.
TA1 · 999 · 277CA · 276/277 · ISA13 and TRN correlation
X12 EDI integration services →Payments and adjustments matched to claim lines, CAS group codes read correctly, PLB adjustments handled, and anything that does not match sent to an exception queue instead of posted blind.
835 · CAS CO, PR, OA, PI · CARC · RARC · PLB
Payment posting automation →Denials grouped by CARC and RARC with the fix attached, resubmission as corrected claims, and alerts on missing acknowledgements, stalled batches and silent feeds.
CARC · RARC · claim frequency 7 and 8 · alerts
Integration monitoring and support →Buyer decisions
How you connect decides cost, speed and control for years. We build on all of these paths, so the recommendation follows your volume, payer mix and team.
| Option | Best fit | Trade-offs | What to plan for |
|---|---|---|---|
| Clearinghouse over SFTP batch | Most practices and RCM products; broad payer reach with one connection | Responses arrive in hours or days; file conventions differ per clearinghouse | Enrollment per payer, filename rules, and polling for 999, 277CA and 835 files |
| Clearinghouse real-time API | Eligibility at check-in and claim status inside your product | Often a separate contract line from batch EDI | Confirming the API is entitled before scoping, and rate limits |
| Direct payer connection | High volume with a few large payers, or payer-owned portals and APIs | One connection, enrollment and test cycle per payer | Payer onboarding queues and separate companion guides |
| RCM platform built-ins | Teams already on athenaOne, eClinicalWorks, AdvancedMD or similar | Limited to what the vendor exposes | Vendor API access, marketplace terms and data export limits |
| Interoply (our platform) | Products that want X12, HL7 and FHIR behind one API | Deployed per customer, in your cloud or ours | Fit with your hosting and data residency rules |
| Build in-house on an X12 library | A strong engineering team with a narrow scope | You own parsing, envelopes, retries, replay and monitoring | Budgeting for the long tail: corrected claims, reversals and payer edge cases |
Most products end up with a clearinghouse for reach plus one or two direct or API connections where speed matters.
Integration boundaries
Revenue workflows cross four organizations. We write ownership down before the build so nothing falls between them.
Source of encounters, charges, diagnoses and provider data. We map what it exposes and list every claim field that has no clean source yet.
Coding, charge review, claim corrections, appeals and posting policy. Our work queues give them the reason and the fix; they make the call.
Payer routing, front-end edits, 999 and 277CA acknowledgements and payer enrollment support. We handle the connection, the conventions and the enrollment paperwork trail.
Adjudication, 277 status, 835 remittance and prior authorization decisions. We integrate with what each payer supports and document the gaps.
Mapping, validation, transport, correlation, retries, replay, audit logging and alerts. Defects here are ours to fix. We sign a BAA and work inside our ISO 27001:2022 certified management system.
Deliverables
Everything below lands in your repository and your runbook.
Transactions in scope, field mappings from source to X12, payer and clearinghouse conventions, and annotated sample files.
Versioned interfaces or services in your repository, with per-payer settings held in configuration.
Every payer, transaction and provider identifier that needs enrollment, with status and owner.
Accepted, rejected, corrected, voided, partially paid and reversed claims, with results against the simulator and the clearinghouse test environment.
CAS and CARC handling, match rules, tolerances and the queue design your billing team signed off.
Alerts for missing acknowledgements and stalled files, replay procedure and escalation contacts.
Delivery phases
A first clearinghouse connection covering eligibility, claims, acknowledgements and remittance typically takes 8 to 14 weeks. Payer enrollment sets most of that date, so we file it in week one and build while it moves.
Weeks 1 to 2
Transaction inventory, source mapping, clearinghouse account and payer enrollment filed
Weeks 2 to 7
Eligibility, 837 build, acknowledgement correlation and 835 parsing built and tested with no PHI
Weeks 6 to 11
Test files through the clearinghouse, rejections fixed, posting rules signed off
Weeks 10 to 14
Production cutover, first remittance cycle reconciled, monitoring and runbook handed over
Cost drivers
You get a fixed scope after one scoping call. These are the factors that move it.
Eligibility alone is the smallest unit. Adding claims, status and 835 posting adds a reconciliation workstream.
Professional, institutional and dental claims each have their own implementation guide and edits.
Each clearinghouse has its own conventions; each direct payer adds enrollment, testing and a companion guide.
A documented FHIR or HL7 feed is faster than reverse-engineering a database or a vendor export.
Auto-posting clean 835 lines is straightforward; reversals, recoupments and PLB adjustments need agreed rules.
Ongoing monitoring, payer changes and on-call are priced per connection.
Proof
Client names are withheld. The code and tools linked here are public.
Built and run for a US behavioral health group: the signed session note becomes the 837P claim, eligibility is checked before every visit, and denials land in a work queue with the payer's own CARC and RARC reason attached. Our first clearinghouse test passed when it should have failed, so every test now takes the exact path production takes.
Built for a US wound care provider group: coverage checked against the clearinghouse before the visit, the dense 271 benefit response read into plain terms for the front desk, and a CPT, modifier and NCCI scrub before any claim leaves the building.
A drop-in stand-in for a real clearinghouse SFTP connection: 120 scenarios across 270/271, 278, 837, TA1 and 999, 277CA, 835 and 276/277, with your own control numbers, trace numbers and patient control numbers echoed back so correlation code is tested before enrollment finishes.
View the simulator on GitHub →Our FHIR prior authorization server for the Da Vinci PAS guide, the FHIR path payers must offer under CMS-0057-F, tested with the Inferno test kit.
View the PAS server on GitHub →We are ISO 27001:2022 certified and sign Business Associate Agreements for work that touches patient data.
FAQ
RCM integration connects the systems that turn care into payment: the EHR or practice management system, the billing or RCM platform, the clearinghouse and payers. It covers eligibility checks, claim creation and submission, acknowledgements, claim status, remittance posting and denial handling, so data moves once and every response lands on the right record.
We map what the EHR exposes (FHIR APIs, HL7 DFT^P03 charge feeds, scheduled extracts or a vendor API) to the claim data the billing system needs: patient and insurance, providers with NPI and taxonomy, ICD-10-CM diagnoses, CPT and HCPCS lines and modifiers. Then we build the return path so claim status, denials and payments flow back to the encounter.
The HIPAA-adopted version 5010 set: 270/271 eligibility, 837P, 837I and 837D claims, TA1 and 999 acknowledgements, 277CA claim acknowledgements, 276/277 claim status, 835 remittance, and 278 prior authorization where payers support it. The 834 and 820 cover enrollment and premium payment for plan-side products.
Most teams start with a clearinghouse such as Availity, Waystar, Change Healthcare or Office Ally because one connection reaches thousands of payers. Direct payer connections make sense for a few high-volume payers or where a payer API is faster. Many products run both, and we design the routing so each claim takes the right path.
Most clearinghouses run on SFTP batch. We build a connector that uploads 837 and 270 files with the clearinghouse's naming rules, polls the download folders, routes each inbound file by its ISA and ST content rather than its filename, and correlates every 999, 277CA, 277 and 835 back to the claim in your billing system.
Yes. We match 835 claim payments (CLP) and service lines (SVC) to your claims, apply CAS adjustments by group code (CO contractual, PR patient responsibility, OA other, PI payer initiated), handle PLB provider-level adjustments and reversals, and send anything that does not match cleanly to an exception queue instead of posting it.
Denials arrive as CARC and RARC codes in the 835 and as rejection codes in the 277CA. We group them by cause, attach the fix your billing team defines (for example a missing modifier or an eligibility gap), and support corrected claims with frequency code 7 or voids with code 8, so resubmission happens in one step.
Buy the clearinghouse connection and payer reach; build the parts that make your product different, such as encounter-to-claim mapping, denial workflows and reconciliation. We also build on RCM platform APIs and on Interoply, our integration platform, when owning the whole stack is not the goal.
A first clearinghouse connection covering eligibility, claims, acknowledgements and remittance typically takes 8 to 14 weeks. Payer enrollment usually sets the date, so we file it in week one and build against our clearinghouse simulator while it moves. Adding payers or transactions later is faster because the conventions live in configuration.
Cost depends on the transactions in scope, claim types, the number of clearinghouses and direct payers, how accessible your source system is, how far you want 835 posting automated, and the support level. We give a fixed scope after one scoping call, before you commit.
No. We are the engineering team that builds and runs the integrations. Coding, claim review, appeals and collections stay with your billing team or billing partner, and our work queues give them the payer's reason and the fix in one place.
Yes. We sign Business Associate Agreements and work inside our ISO 27001:2022 certified management system. Development runs against synthetic claims and our clearinghouse simulator, production traffic is encrypted in transit and at rest, and access to claim data is logged.
Next step
Tell us your EHR, billing system, clearinghouse and the step where claims get stuck. An integration engineer replies with the transactions in scope, the enrollment you need and a fixed scope.
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Tell us about your EHR, billing system, clearinghouse and payers, and the step that fails. We reply with the scope and dependencies.
