Case Study: Modernizing EDI for a Leading U.S. Healthcare Insurance Provider

A leading healthcare insurance provider in the U.S., serving more than 100K+ members, was struggling with operational bottlenecks due to a poorly implemented EDI system.

Instead of streamlining processes, the legacy EDI platform created frequent disruptions in core areas such as claims management, eligibility verification, and provider enrolment.

Key Challenges:

  1. High claims rejection rate: Nearly 15–18% of claims were being rejected due to mapping errors and data mismatches.
  2. Compliance risks: Delays in implementing HIPAA X12 5010 standards led to recurring audit findings and penalties.
  3. Slow partner onboarding: Provider and trading partner onboarding averaged 6–8 weeks, impacting member access to services.
  4. Operational inefficiency: Over 25% of transactions required manual rework, increasing processing costs.
  5. Member experience impact: Delays in claims and eligibility verification negatively affected satisfaction scores.

AD Infosystem’s Solution

When this leading healthcare insurance provider turned to us, their EDI system was holding them back—slows claims, compliance headaches, and frustrated members. They needed more than just a technology upgrade; they needed a partner who could help them move faster, reduce errors, and deliver better care experiences.

At AD Infosystem, we stepped in to:

  • Modernize their EDI with a HIPAA-compliant, cloud-based platform.
  • Automate claims, eligibility, and remittance processes, cutting rejection rates by over 80%.
  • Integrate seamlessly with their core systems, giving them real-time visibility into every transaction.
  • Scale effortlessly, so they could onboard new providers in days, not months.

The result?

  • Claims got processed faster.
  • Members experienced smoother care journeys.
  • Costs dropped while compliance stayed rock solid.

With AD Infosystem, technology stopped being a bottleneck—and became a strategic enabler of better healthcare outcomes.

Client Testimonial

"We’ve seen a massive turnaround in claims processing speed and operational transparency. AD Infosystem’s EDI solution helped modernize our healthcare workflows and saved both time and cost."

— CIO, Leading Healthcare Group (Client Confidential)

Author
Pallavi Sogani ([email protected])
EDI Solution Architect
AD Infosystem LLC

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