A government programs health plan answers to CMS and to every state it serves, through files that must reconcile month after month. Agnotic Technologies builds the enrollment, payment, encounter and dual eligible data exchanges behind Medicare Advantage, Medicaid managed care and D-SNP plans.
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Medicare Advantage and Medicaid plan software runs the data exchanges only government programs health plans have: enrollment and payment reconciliation with CMS, encounter data for risk adjustment, Medicaid managed care encounter and enrollment files with each state, and D-SNP coordination for dual eligible members. Agnotic Technologies builds these pipelines and reconciliation tools for health plans.
Each program brings its own counterparty and rules. Many plans run more than one, and the software has to keep them apart.
Contracts with CMS and exchanges enrollment, payment and risk adjustment data with it.
Contracts with a State Medicaid agency, often in several states.
A Medicare Advantage plan with a contract with the State Medicaid agency.
The same program, with a different companion guide in each state.
The gaps we look for first, because each one costs revenue or a compliance finding.
Membership in the core system differs from the members CMS paid for, so the plan covers people it is not paid for, or the other way round.
Enrollment rejections sit in a folder and are never worked.
Encounters the state rejects are never corrected and resubmitted.
Encounter records are missing the identifiers of the provider who delivered the service.
D-SNP admission notices go late, or only for some hospitals.
Medicaid members lose coverage at renewal, return a month later and get a second member ID.
Each state's file layout is handled by a separate script that only one person understands.
The table we start every engagement with. Counterparties and formats come from the regulations and your contracts; the exact layouts and schedules come from CMS instructions and each state's companion guide, which we build to as written.
| Data exchange | Counterparty | Cadence | Format or standard | Reconciliation check |
|---|---|---|---|---|
| Medicare Advantage enrollment and disenrollment, and the replies | CMS | As members join, change or leave | CMS enrollment transaction layouts | Every transaction has a reply, and every rejection is worked |
| Membership and payment reconciliation | CMS | Monthly, as CMS pays in advance for each month | CMS membership and payment reports | Members in the core system equal members CMS paid for, month by month |
| Risk adjustment data | CMS | On the schedule CMS instructions set | As CMS instructions specify | Each submitted record accepted, or corrected and resubmitted |
| Medicaid enrollment | State Medicaid agency | Set by the State contract | ASC X12 834 | Members in the state file equal members in the core system |
| Medicaid encounter data | State Medicaid agency | Set by CMS and the State | ASC X12N 837, NCPDP and ASC X12N 835 as appropriate | State acceptance and validation tracked per encounter |
| D-SNP admission notifications | State Medicaid agency or its designee | Timeframe set by the State | Method set by the State | Every qualifying hospital or SNF admission notified on time |
Three design choices that make month-end reconciliation routine.
For each member and month, the ledger holds what the core system says, what CMS or the state says and what was paid. Every difference is a line someone owns.
Rejections, errors and validation results become queue items with an owner and a due date, not files in a shared folder.
File layouts, schedules and rules per state live in configuration with tests, so a new state contract is a set-up task, not a new script.
Components we build around your core administration system.
Builds outbound transactions, reads replies and matches each one to the member and the request.
The member ledger, with differences grouped by cause and assigned to an owner.
Encounters assembled from claims, validated before sending and tracked through acceptance.
Every rejected record with its reason, the fix applied and the resubmission.
Enrollment and encounter files per state, driven by tested configuration.
Admission events turned into notices to the State in the method and timeframe it sets.
Medicaid renewal dates, coverage gaps and members who return, linked to one identity.
Who sent, received, changed or resolved each record, and when.
We build to the published standards and to your contracts' companion guides.
Measures we build into the reconciliation workbench.
Members where the core system, CMS or state and payment all agree.
Differences between expected and received payment, grouped by reason.
Submitted encounters accepted, rejected and resubmitted.
Admission notices sent within the State's timeframe.
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A women’s health product experience focused on guided care journeys, education, and compliance-aware workflows to support long-term engagement.
Plans and their administrators, at launch or when they outgrow manual work.
Enrollment and payment reconciliation moved off spreadsheets.
Government program data exchanges for a health system's own plan.
State files and encounter submission set up from the companion guide.
State contract duties, including admission notifications, built in.
One platform that keeps each plan's contracts and data apart.
Encounter and enrollment gaps closed with a full audit trail.
The systems around the member ledger.
We build secure, scalable products designed for privacy, interoperability, and regulatory readiness from day one across every sector we serve.
Protect PHI with privacy-first architecture, encrypted storage and transmission, and strict access controls.
We combine deep technical expertise with industry-specific knowledge to deliver solutions that aren't just functional, but transformational.
We implement rigorous security protocols and compliance standards (HIPAA, GDPR, SOC2) across all industrial solutions to protect sensitive data.
Our architectures are built to handle massive data loads and user bases, keeping performance steady whether you're serving ten or ten million.
Using our suite of internal tools and proven frameworks, we cut setup work so your first release reaches users sooner.
Beyond simple wrappers, we build deep-learning integrations and predictive analytics directly into the core of your industry-specific workflows.
We start from your exchange inventory. Timing depends on scope; we agree a fixed first release on the scoping call.
We review your programs, states, core system and where reconciliation breaks today.
The reference table above, filled in for your plan, with owners for each exchange.
One exchange working end to end, usually monthly membership reconciliation.
Encounters, state files and D-SNP notices added on the same ledger.
Companion guide and contract updates handled under change control.
Short facts we design the ledger and the exchanges around, each linked to its primary source.
CMS makes advance monthly payments to Medicare Advantage organizations for each enrollee in an MA payment area for the month.
Source: 42 CFR 422.304(a) (eCFR)Each Medicare Advantage organization must submit to CMS, in accordance with CMS instructions, the data needed to characterize the context and purposes of each item and service provided to an enrollee.
Source: 42 CFR 422.310(b) (eCFR)State contracts with Medicaid managed care plans must require encounter data that identifies the provider of each service, submitted to the State at a frequency set by CMS and the State, in ASC X12N 837 and NCPDP formats and the ASC X12N 835 format as appropriate.
Source: 42 CFR 438.242(c) (eCFR)A dual eligible special needs plan that is not fully or highly integrated must notify the State Medicaid agency, or its designee, of hospital and skilled nursing facility admissions for at least one group of high-risk full-benefit dual eligible members, in the timeframe and method the State sets.
Source: 42 CFR 422.107(d)(1) (eCFR)Medicaid eligibility based on MAGI income must be renewed once every 12 months, and the agency must renew without asking the member for information when reliable data it already holds is enough.
Source: 42 CFR 435.916(a) (eCFR)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
This page covers CMS and state data exchanges. These pages cover the APIs, analytics and core systems around them.
Includes the CMS-0057-F interoperability and prior authorization APIs.
Modernizing or extending the core admin platform.
HCC gap analytics and Star Ratings work.
Claims, member and provider operations.
834, 837 and 835 transaction builds and testing.
Explore other production-grade engineering platforms we deliver across healthcare.
The technical patterns behind this platform translate naturally into adjacent verticals.
