Healthcare RCM Software Development
Develop software for the work between care delivery and reimbursement. Connect workflows, surface exceptions, and support the teams responsible for resolving them.
The challenge behind the brief
Healthcare RCM software development is the engineering of the systems that carry a patient encounter to a paid, posted and reconciled claim. We build that software for provider groups, billing companies and health tech vendors: eligibility with the 270/271, claim creation and submission with the 837P and 837I, acknowledgment handling with the 999 and 277CA, claim status with the 276/277, prior authorization with the 278, and payment posting from the 835 ERA.
The difficult part of RCM software is rarely the user interface. It is the transaction layer: companion guide rules that differ by payer, clearinghouse enrollment, loop and segment mapping, CARC and RARC codes that decide whether a denial is worth working, and 835 remittances that must balance to the penny before they post. That is the layer we engineer, test against real X12 files and hand over with monitoring your billing team can read.
Connect to Availity, Waystar, Change Healthcare (Optum) or direct payer connections through one normalized API, inspect any X12 file with our free X12 EDI Inspector, or start with the integration work alone through our RCM integration services.
Define the right scope
Real-time and batch 270 inquiries before the visit, with 271 responses parsed into plan, coverage dates, copay, coinsurance, deductible remaining and service type benefits. Inactive coverage, coordination of benefits flags and missing subscriber data become work queue items before the patient arrives, not denials 30 days later.
Charges built from encounter data through HL7 v2 DFT messages or FHIR (Encounter, Procedure, Claim, ChargeItem), with CPT and HCPCS codes, modifiers, ICD-10-CM diagnosis pointers, NPI and taxonomy for billing, rendering and referring providers, and place of service. Missing charges are reconciled against the schedule so nothing seen goes unbilled.
An editable rules engine that runs before the 837 leaves: NCCI procedure-to-procedure edits and MUEs, modifier logic, diagnosis-to-procedure pointer checks, timely filing windows, payer-specific companion guide rules and front-end clearinghouse edits. Every rule carries an owner, a reason and a test file, so billers can see why a claim was held.
Professional and institutional claims generated loop by loop, validated against the 005010 implementation guides, batched and sent over SFTP or API to the clearinghouse. 999 and 277CA acknowledgments are matched back to each claim, so a rejected claim is flagged within the day with the exact segment and reason.
835 adjustments and 277 rejections are classified by CARC, RARC and group code (CO, PR, OA, PI) into categories your team works: eligibility, authorization, coding, medical necessity, duplicate, timely filing and contractual. Work queues route by category and dollar value, and appeal letters pull the claim, the remark code and the clinical documentation together.
835 remittances parsed into claim-level and service-line payments and adjustments, auto-posted when the claim matches and the math balances, and reconciled to the bank deposit through the TRN trace number. PLB provider-level adjustments, recoupments and reversals go to a reconciliation queue instead of silently changing balances.
Scheduled 276 inquiries for claims without an adjudication response, with 277 status codes driving follow-up. Prior authorization requests sent as X12 278 through the clearinghouse or, for payers moving to the CMS-0057-F Prior Authorization API, as FHIR requests following the Da Vinci PAS implementation guide.
Patient responsibility calculated from the 835 PR adjustments, statements generated on your cycle, card and ACH payments through a PCI DSS compliant processor, payment plans, and good faith estimates for self-pay patients under the No Surprises Act.
Clean claim rate, first-pass resolution, denial rate by CARC and payer, days in AR, AR aging buckets, net collection rate and posting lag, calculated from the same claim, remittance and adjustment tables that drive the workflow, so the dashboard and the ledger always agree.
Explore the service in detail
Clearinghouse integration
One normalized claims API in front of Availity, Waystar, Change Healthcare (Optum) and direct payer connections.
Claim scrubber and rules engine
Configurable edits that stop rejections and denials before the 837 is sent.
Denial management and appeals
Worklists built on CARC, RARC and group codes rather than free-text notes.
ERA posting and payment reconciliation
835 auto-posting that balances before it posts.
Eligibility and prior authorization
Front-end checks that prevent the most common denials.
X12 EDI engineering and testing
The transaction layer, built and tested against real file structures.
What to evaluate in your partner
Our engineers read 837 loops, 835 CAS segments and 277CA status codes directly. We keep an open-source X12 clearinghouse simulator on the Nirmitee-tech GitHub organization covering 270/271, 278, 837, 999/277CA, 835 and 276/277, and use it to test every workflow before a clearinghouse ever sees a file.
Every held claim, rejection and unposted remittance lands in a queue with the reason in plain language and the X12 detail one click away. Billers resolve work without asking engineering what a segment means.
We sign BAAs, and Nirmitee is ISO 27001:2022 certified. PHI is encrypted in transit and at rest, access is role based, and audit logs record who viewed or changed each claim.
EHR and practice management systems on the clinical side (HL7 v2, FHIR, vendor APIs), clearinghouses and payers on the financial side. One team owns the full path from encounter to posted payment.
Source code, infrastructure as code, test files and runbooks are delivered to your repositories. Your team can extend the rules engine and add payers without us.
A reviewable delivery approach
Transaction layer first, workflow second, cutover payer by payer.
Map the current workflow from scheduling to posting, pull a sample of 835s and rejection reports, and rank the denial categories by dollar impact.
Deliverables: workflow map, payer and clearinghouse inventory, denial analysis by CARC and payer, and a prioritized build scope.
Build the X12 parsers and generators, clearinghouse connectivity and EHR charge feed first, because every later feature depends on them.
Deliverables: 837, 835, 270/271 and 276/277 handling, clearinghouse test file sign-off and an EHR charge interface.
Claim scrubber, denial worklists, ERA posting and patient statements built on the transaction layer, with rules your billers can edit.
Deliverables: work queues, rules engine, posting and reconciliation, statements and payments.
Run new claims and remittances alongside the current process, compare results, then cut over payer by payer with monitoring on every file.
Deliverables: reconciliation report, cutover plan, alerting on file failures and rejections, and ongoing support.
Evaluating an integration or product partner? Explore the systems, workflows, and technical decisions behind our work.
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Explore the implementationA working model for your priorities
Define the scope, ownership, and delivery responsibilities together. Commercial terms and team availability follow that conversation.
Bring a product or integration milestone. Agree the dependencies, deliverables, and acceptance criteria before implementation.
Explore engineering, integration, design, and QA support that works with your existing product and technical leads.
Before you choose a partner
It covers the software between a patient encounter and a posted payment: eligibility verification (270/271), charge capture from the EHR, claim scrubbing, 837P and 837I claim submission, acknowledgment handling (999, 277CA), claim status (276/277), prior authorization (278), denial management with CARC and RARC codes, 835 ERA posting, patient statements and revenue analytics.
The core set is the 837P and 837I for claims, 835 for remittance, 270/271 for eligibility, 276/277 for claim status, 278 for prior authorization, and the 999 and 277CA acknowledgments. Some workflows also need the 275 for attachments and the 834 or 820 on the payer side. All follow the HIPAA-mandated 005010 implementation guides plus each payer's companion guide.
Yes. We build clearinghouse integrations to Availity, Waystar and Change Healthcare (Optum), and direct payer connections where a payer offers them. We put a normalized claims API in front of them so your application does not depend on one clearinghouse's file formats or report layouts, and switching or adding a clearinghouse is a configuration change.
Buy when an off-the-shelf platform covers your specialties, payers and workflow. Build, or extend, when you are a health tech company embedding billing in your product, when your specialty has payer rules the platforms handle poorly, or when you need denial and posting logic you control. Many clients keep their practice management system and build the scrubber, denial and analytics layers around it.
A scrubber checks each claim before submission against NCCI procedure-to-procedure edits, MUE unit limits, modifier rules, diagnosis pointers, timely filing and payer companion guide rules. Claims that would be rejected or denied are held with the rule, field and fix shown to the biller, so errors are corrected before the payer sees them.
Claim Adjustment Reason Codes explain why a payment was adjusted, Remittance Advice Remark Codes add detail, and the group code (CO, PR, OA, PI) says who is responsible. We map each combination to a root cause category and an action, such as correct and resubmit, appeal, bill the patient or write off, and route the claim to the right queue.
The 835 is parsed into claim and service-line payments and CAS adjustments, matched to the original claim by patient control number and service lines, and posted automatically when everything balances. The TRN trace number reconciles the remittance to the EFT deposit. Provider-level adjustments, recoupments and mismatches go to an exception queue instead of posting blindly.
Yes. We support X12 278 requests through the clearinghouse today and FHIR-based prior authorization using the Da Vinci CRD, DTR and PAS implementation guides for payers implementing the CMS-0057-F Prior Authorization API, with authorization numbers carried onto the claim automatically.
Every parser, generator and rule runs in CI against a library of X12 test files, including payer-specific edge cases. We use our open-source clearinghouse simulator for end-to-end tests, clear test files with each clearinghouse, and run a parallel period where new claims and remittances are compared with the existing process before cutover.
We sign BAAs and Nirmitee is ISO 27001:2022 certified. Claims and remittance data are encrypted in transit and at rest, access is role based, EDI files are stored with retention rules, and audit logs record every view and change to a claim or payment.
It depends on scope. A clearinghouse integration with eligibility, claim submission and ERA posting is a smaller project than a full billing platform with scrubbing, denial management, statements and analytics. We scope it in discovery by counting the transactions, payers, clearinghouses and EHR interfaces involved, and deliver in phases so the transaction layer is in production first.
Yes. We connect to EHR and practice management systems through HL7 v2 DFT and ADT feeds, FHIR APIs and vendor APIs, pulling encounters and charges in and writing claim status, payments and adjustments back, so staff keep working in the system they already use.
Let’s make the next step useful
Discuss your workflows, systems, and delivery priorities with the Nirmitee team.
