Data coming in
Files and feeds that put members, providers and claims into the core.
- 834 enrollment files from employer groups and exchanges
- Provider roster and credentialing loads
- 837 claims from clearinghouses
Healthcare / HealthEdge Platforms
Integration and support around HealthEdge healthcare platforms
A health plan that has bought its core administration platform still has to feed it, connect it and test it every time it changes. Agnotic Technologies builds the enrollment and claims interfaces, portals, APIs and regression suites around the HealthEdge platform your plan runs, and supports them after go-live.
834
Enrollment feeds into the core
837 · 835
Claims in, remittance out
Every upgrade
Benefit configuration regression tested
Trusted by global innovators
Industry Overview
What does integration around HealthEdge healthcare platforms involve?
Integration around HealthEdge healthcare platforms is the engineering a health plan needs after it buys a core administration platform: enrollment and claims feeds, provider data loads, member and broker portals, APIs and regression tests for each upgrade. Agnotic Technologies builds and supports this work around the platform your plan already runs, without changing the platform itself.
Around the core
What sits around a purchased core platform?
The core holds members, benefits, providers and claims. These are the four areas of work we build around it. Agnotic Technologies is independent of HealthEdge; we build for the plan, not for the vendor.
Data going out
What leaves the core for providers, partners and your own teams.
- 835 remittance files
- Data warehouse and reporting extracts
- Files for pharmacy, dental or care management partners
Apps for members, providers and brokers
The screens people use instead of calling the plan.
- Member portal and mobile app
- Provider and broker portals
- Lookup tools for service staff
APIs and testing
The layer that keeps the core reachable and its changes safe to release.
- FHIR APIs around the core for CMS-0057-F
- Integration test environments
- Regression suites for benefit configuration
Industry Challenges
Why does a health plan still need engineering after buying a core platform?
Buying a core platform puts the plan's benefit and claims rules in one system. The data and apps around that system stay the plan's job.
Employer groups send 834 files with their own quirks, and each new group means another mapping and another round of test files.
Provider data arrives from credentialing, contracting and roster spreadsheets that do not match what the core loads.
A platform upgrade or benefit change can alter how a claim prices or adjudicates, and manual test scripts are slow to rerun.
Member and provider portals read from the core, so a changed interface shows up as wrong balances or missing claims.
Finance, actuarial and quality teams need extracts in a shape the core does not produce.
CMS-0057-F asks impacted payers for FHIR APIs, and the data behind them sits in the core and the systems around it.
Decision table
Where should each change live: in the core, around it, or in a new build?
The first question we ask about every request. Keeping the core close to its supported configuration makes upgrades easier; custom logic goes where it can be tested and changed on its own.
| Request | Where it belongs | Why | What we build |
|---|---|---|---|
| New benefit plan or rider | Core configuration, set by your configuration team | Benefit rules belong in the system that adjudicates against them | Regression cases that show the new plan prices claims as expected |
| New employer group with its own 834 layout | Around the core | Group-specific layouts change often and should not touch core logic | A mapping and validation layer that turns each group's file into a clean 834 for the core |
| Provider roster from a delegated group | Around the core | Roster formats vary by group and need checks before load | Roster intake, validation, an exception queue and the load file |
| Claims and accumulators in the member portal | Around the core | Members need a fast read model, not a call to the core on every page view | A portal backend with a read store refreshed from the core's interfaces |
| Provider Access or Payer-to-Payer API | Around the core | The FHIR resources combine core data with clinical and authorization data | A FHIR R4 API layer, mapping from core extracts, consent and access controls |
| Replacing the core itself | A separate project | Building or replacing a core is its own decision with its own risks | Covered on our payer core administration page |
Our Approach
How do we work around a core platform without changing it?
Four rules keep the core stable while the systems around it change.
Use the interfaces the platform offers
We connect through the files, APIs and extracts your platform supports and your vendor agreement allows, never through direct writes to its database.
Validate before the core sees it
Inbound files are checked against the X12 implementation guide and your plan's rules first, so bad records land in an exception queue, not in member data.
Keep custom logic outside
Group mappings, portal logic and reporting live in services you own, so a platform upgrade does not overwrite them.
Test every change the same way
A regression suite of known members, benefits and claims runs before each upgrade or configuration release.
Capabilities
What do we build around HealthEdge healthcare platforms?
Integration, data and application work for health plans and TPAs that run a HealthEdge platform.
834 enrollment intake
Per-group mapping, validation against the 005010X220 guide, change detection and an exception queue before a file reaches the core.
Claims intake and remittance
837 intake from clearinghouses with front-end edits, and 835 files from the core delivered to providers and clearinghouses.
Provider data pipelines
Roster, credentialing and contract data cleaned, matched and loaded, with a report of what changed in each load.
Member, provider and broker portals
Web and mobile apps that show eligibility, claims, accumulators and ID cards from data the core publishes.
FHIR APIs around the core
Provider Access, Payer-to-Payer and Prior Authorization APIs on FHIR R4, fed from core extracts and other plan systems.
Reporting and warehouse extracts
Scheduled extracts into your data warehouse for finance, actuarial, quality and audit teams.
Data conversion
Member, accumulator, provider and claim history moved from a legacy system into the new platform, with reconciliation reports.
Upgrade regression testing
Automated suites of members, benefits and claims rerun on every platform upgrade or configuration release, with the differences reported.
How It Works
How does an upgrade regression run work?
The flow we set up so a platform upgrade or benefit change ships with evidence. It runs in a non-production environment with synthetic members.
Build the test bed
Synthetic members, groups, providers and benefit plans that cover your products, loaded into a test environment.
01
1
Record the baseline
Test claims run through the current version, and the priced and adjudicated results are stored as the expected outcome.
02
2
Apply the change
Your team or the vendor applies the upgrade or configuration release in the test environment.
03
3
Rerun and compare
The same claims, enrollment files and portal calls run again, and every difference in pricing, adjudication or output files is listed.
04
4
Review the differences
Your configuration and claims leads mark each difference as expected or as a defect.
05
5
Release with evidence
The signed-off comparison is kept as the release record for audit and as the baseline for the next upgrade.
06
6
Engineering Stack
Standards and tools around the core
The transactions, APIs and tooling behind the work we build around a payer core platform.
X12 transactions
834 enrollment837P and 837I claims835 remittance270/271 and 276/277
APIs
HL7 FHIR R4US Core and payer implementation guidesOAuth 2.0REST
Data movement
SFTP and managed file transferMessage queuesPostgreSQLData warehouse loaders
Testing
Synthetic member generatorsX12 validatorsAutomated regression in CIPlaywright for portals
Measured Impact
What should a health plan measure around its core?
Measures we build reporting around, agreed with your operations and IT leads.
Exceptions
834 records held for review
By group and reason, so recurring errors are fixed at the source.
Load time
File received to member active
Time from an 834 arriving to the change being live in the core.
Differences
Changed results per release
Claims whose price or adjudication changed after an upgrade, expected or not.
Freshness
Lag between core and portal
How far behind the core the member and provider portals run.
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Use Cases
Who asks us for work around a core platform?
Teams that run a purchased core platform and need engineering around it.
01
Regional health plans
Plans that run the core themselves and need interfaces, portals and testing around it.
02
Medicare Advantage and Medicaid plans
Plans with CMS-0057-F API work and regulatory reporting fed from the core.
03
Third-party administrators
TPAs that load many employer groups, each with its own 834 layout and reporting needs.
04
Plans in implementation
Teams moving onto a new core platform who need data conversion and interface builds.
05
Plans after go-live
Teams that need interfaces supported and regression tested on each upgrade.
06
Provider-sponsored plans
Health systems that run a plan and need its core connected to their own systems.
Integrations
Which systems connect to the core?
The systems on either side of the work we build.
Your core
The HealthEdge platform your plan runs
Claims and remittance
Clearinghouses
Enrollment
Employer groups and exchanges
Provider data
Credentialing and contracting systems
Reporting
Data warehouse
Apps
Member and provider portals
Compliance-First Development Services Backed by Global Standards
We build secure, scalable products designed for privacy, interoperability, and regulatory readiness from day one across every sector we serve.
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, and strict access controls.
Fast Healthcare Interoperability Resources
Enabling standardized health data exchange through standards-based API mappings.
Our Edge
Why Global Leaders Choose Us
We combine deep technical expertise with industry-specific knowledge to deliver solutions that aren't just functional, but transformational.
Enterprise-Grade Security
We implement rigorous security protocols and compliance standards (HIPAA, GDPR, SOC2) across all industrial solutions to protect sensitive data.
High-Performance Scaling
Our architectures are built to handle massive data loads and user bases, keeping performance steady whether you're serving ten or ten million.
Accelerated Time-to-Market
Using our suite of internal tools and proven frameworks, we reduce development cycles and get your product to market 40% faster.
Embedded AI Integration
Beyond simple wrappers, we build deep-learning integrations and predictive analytics directly into the core of your industry-specific workflows.
Engagement Model
How does an engagement work?
We start with one interface or one test suite. Timing depends on scope; we agree a fixed first release on the scoping call.
01
Scoping call
We agree the first piece of work, the systems involved and who owns the vendor relationship.
02
Confirm the interfaces
The files, APIs and environments we may use are confirmed in writing with your team and, where needed, your platform vendor.
03
Fixed-scope first release
One interface or one regression suite built and tested end to end, often the 834 intake or the upgrade test bed.
04
Add the next pieces
Further interfaces, portals or APIs, one at a time, each with its own tests.
05
Scale and support
Interfaces and test suites kept current through each platform upgrade under agreed support terms.
Facts and sources
Which rules shape the work around a payer core?
Short facts from HIPAA and the CMS interoperability rule, each linked to its primary source.
HIPAA adopts the ASC X12 834 Benefit Enrollment and Maintenance transaction (005010X220) as the standard for enrollment and disenrollment in a health plan.
Source: 45 CFR 162.1502 (eCFR)HIPAA names the ASC X12 837 Health Care Claim technical reports, including 005010X222 for professional claims and 005010X223 for institutional claims, as standards for the health care claims transaction.
Source: 45 CFR 162.1102 (eCFR)HIPAA adopts the ASC X12 835 Health Care Claim Payment/Advice (005010X221) as the standard for health care remittance advice.
Source: 45 CFR 162.1602(d)(2) (eCFR)A HIPAA covered entity may use a business associate to conduct all or part of a standard transaction, and must require that business associate, and any agent or subcontractor, to comply with the Part 162 requirements.
Source: 45 CFR 162.923(c) (eCFR)CMS-0057-F requires impacted payers to build a FHIR-based Prior Authorization API, along with Provider Access and Payer-to-Payer APIs, with compliance dates generally beginning January 1, 2027.
Source: Federal Register, February 8, 2024 (CMS-0057-F)
Voice of success
We don't just build products; we forge lasting partnerships. See how we've helped industry leaders transform their vision into technical reality.
“I can clearly see how Agnotic has a unique way of handling end-to-end development. They are always active on quick chat and provide support quickly.”
Aaron Phelan
Founder, Benchmark
“Agnotic combines deep technical expertise with strong domain knowledge. They understand the business context, anticipate challenges, and make collaboration smooth and effective.”
John Pasmore
Founder, Latimer
“Agnotic is the best technical team we evaluated. Their engineering excellence made our work dramatically easier and allowed us to stay focused on what matters most for maternal care outcomes. They took full ownership of the technical execution, and we are always happy to continue working together.”
Kim Smith
Founder, My Lauren
Related pages
Related payer software services
This page covers work around a core your plan already runs. These pages cover building the core, the operations around it and claims adjudication.
Payer core administration software development
Building core modules, or replacing a legacy core one module at a time.
Payer operations software development
Service, appeals and authorization workflow tools for health plan teams.
Claims adjudication software development
Adjudication systems for payers and TPAs, from intake to remittance.
Software development for health plans and payers
CMS-0057-F APIs, prior authorization, member and provider portals.
X12 EDI integration
834, 837, 835, 270/271 and 276/277 transactions with trading partners.
HIPAA requirements for software teams
The safeguards we build into every system that holds patient or member data.
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Frequently Asked Questions
No. Agnotic Technologies is an independent software development services company. We build integrations, apps and tests around the HealthEdge platform your plan already runs; your license, product support and roadmap questions stay between you and HealthEdge.
Yes, through the files, APIs and extracts your platform and vendor agreement support. We confirm which interfaces your environment exposes before we design anything, then build the mapping, validation and monitoring on your side.
Yes. Enrollment, claims and member data are protected health information, so Agnotic signs a business associate agreement with you before any data reaches our team. Test environments use synthetic members wherever possible.
Yes. Most plans start with one interface, such as 834 intake for a set of employer groups, or with the upgrade regression test bed. We agree that scope on the scoping call.
The number of interfaces and trading partners, the quality of the source files, portal and API scope, data conversion volume and how much regression testing you want automated. We explain these drivers on the scoping call instead of quoting a price before it.
It depends on scope. We agree a fixed first release on the scoping call, usually one interface or one test suite, and give you a timeline for that release.
Role-based access, encryption in transit and at rest, audit logs on every file transfer and API call, and synthetic data in test. HIPAA has no certification for software, so we document the safeguards instead of claiming a badge.
AI tools help our engineers draft mappings, code and test cases. An engineer reviews every change, and nothing ships until it passes the regression suite built from your plan's own scenarios.
Industries