Medical billing & claim software development
From patient eligibility verification to prior auth intelligence, we build custom medical billing and claim adjudication solutions for authorities, billing services providers, TPAs, providers and insurers. The software we develop covers the entire healthcare revenue lifecycle, ensuring transparency and automation in defining payment responsibilities.
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Expertise that powers your success
In-depth process understanding
We implement complex implementation guides (IGs) like the Da Vinci Burden Reduction (CRD/DTR/PAS), ensuring compliance and smooth integration, even in fragmented and high-load environments.
Proficiency in modern standards
We focus on medical billing software development that supports HL7 FHIR, X12, and seamless, compliant payer-provider communication and regulatory-ready data exchange.
RCM modules for national HIEs
Our RCM components — eligibility, prior authorization, claims, and payments — have been deployed in national HIEs and built to handle scale, complexity, and compliance.
Expertise in complex, high-load projects
We built Mastercard’s MoneySend hub and Raiffeisen’s retail banking platforms handling millions of transactions with strict security, compliance, and great scalability.
We address local-specific billing challenges
Challenges
USA - Multi-payer interoperability complexity including connectivity to Health Information Networks (HINs) and Qualified Health Information Networks (QHINs) such as eHealth Exchange, and Health Gorilla.
- Regulatory fragmentation across states or regions creates complexity in maintaining billing and compliance workflows.
- Low compatibility and high friction in EDI + FHIR integration workflows (837/835, 270/271, 278, FHIR Claim).
- Lack of standardized FHIR-based eligibility and coverage validation mechanisms.
- Ongoing updates and adaptations are required to comply with evolving CMS interoperability mandates — with Da Vinci Burden Reduction use cases (CRD, DTR, PAS).
- Compliance needs for clinical and financial data handling under HIPAA.
- Difficulties implementing high-patient-responsibility billing workflows.
- Poor EHR and billing system compatibility.
- Fragmented billing experience across systems.
- Challenges in implementation of AI form claim decisions.
EU - Complexity of multi-stakeholder interoperability involving public payers, with connectivity to national reimbursement and exchanges, such as Gematik's Telematikinfrastruktur.
- Need for multi-language document generation and localized billing logic across jurisdictions.
- Complex data normalization and mapping across FHIR, OpenEHR, and HL7v2 standards.
- Barriers to integration with national FHIR registries (NHS, Gematik) due to inconsistent adoption and APIs.
- Country-specific mandates such as MedMij, VIPP, ISiK, and ISiP require localized technical alignment.
- Compliance needs for clinical and financial data handling under GDPR.
- VAT-specific invoicing and cross-border reporting requirements for European healthcare systems.
Solutions
Specialization in healthcare data exchange compliance
We design and implement solutions that align with ONC, CMS, ISiK/ISiP, EHDS, and other national mandates. Our team ensures end-to-end conformance with FHIR IGs, as well as compliance with HIPAA and GDPR requirements for secure data handling.
Built-in localization through Kodjin — our FHIR-native platform
Our proprietary Kodjin data platform serves as a foundation for custom claim & billing solutions, with built-in support for regional interoperability standards like Da Vinci IGs. It simplifies integration with national registries, HIEs, and reimbursement systems across the US and Europe.
Proven track record in national-scale projects
Edeblab’s experience spans diverse regulatory environments — from building a national e-health system in Ukraine to integrating patient-generated data into Austria’s HIE and supporting ongoing U.S. payer integrations.
Custom medical billing software development services we deliver
End-to-end platform development
We build full-featured RCM and Claim adjudication platfroms from the ground up — scalable, secure, and tailored to your workflows.
Future-ready architecture design
Our team designs modular, standards-based architectures that evolve easily with regulatory updates and payer model changes.
Module development
We build and integrate individual RCM and claim adjudication modules: claims, prior authorization, eligibility checks, and more.
Integration services
We connect RCMs and claim engines with EHRs, payer systems, and third-party tools using FHIR, HL7, and other standards.
Migration from legacy systems
We ensure a smooth and secure transition from legacy platforms to modern medical billing solutions without data loss.
Compliance with Da Vinci IGs
We help comply with Da Vinci Burden Reduction (CRD/DTR/PAS) IGs, ensuring simplified prior authorization processes and interoperability.
We build standalone solutions to automate claim and billing processes
Claim auto-adjudication
Our team automates the entire claim processing workflow, applying predefined rules to ensure quick, accurate adjudication with minimal manual intervention.
Reporting
Solutions we provide include on-demand actionable insights that help track performance and optimize revenue cycle operations for better outcomes.
Prior authorization
We streamline the prior authorization process, automating requests and document submissions to reduce delays and improve efficiency.
Coding automation
We leverage AI-driven tools to automate coding, ensuring accuracy and compliance while reducing administrative burden.
Patient eligibility verification
Our team helps automatically verify patient eligibility, reducing claim denials, ensuring correct billing, and accelerating service delivery.
Automated credentialing
We automate the credentialing process, speeding up verification and ensuring providers meet all necessary regulatory requirements.
Case study
Payers & TPAs
Hong Kong Heals.Asia HIE with claim processing
Implementing an FHIR Facade for seamless provider directory access and real-time search by specialty and location. Claim processing optimization with an auto-adjudication engine.
Case study
Govenmental agency
Healthcare financial message exchange hub
Development of a national financial exchange hub enabling seamless connectivity between all providers and all payers. Supports FHIR-based eligibility checks, prior authorizations, and claim clearing.
Data types, standards, and terminologies we work with
Clinical terminologies
ICD-10-CM CPT SNOMED CT LOINC
Patient and demographics
FHIR HL7v2 CSV JSON
Diagnosis and procedures
FHIR CDA OpenEHR DICOM
Claims and billing
FHIR X12 837/835
Financial transactions
FHIR X12 270/271
What sets our custom medical claim management solutions apart
01
High-load scalability
We specialize in medical billing software development, building custom RCM and claim adjudication platforms that can handle high volumes of claims, authorizations, and transactions with speed and accuracy. By leveraging microservices and event-driven architectures, we ensure consistent performance even under peak loads.
02
Semantic interoperability
We enable accurate and efficient data exchange between medical billing systems, payers, and EHRs/HIS using standards like FHIR and X12 along with terminologies such as SNOMED CT, LOINC, ICD-10, and others. Our semantic layer ensures aligned coding and clean, compliant claims.
03
Cost-efficient maintenance
Our modular architecture and smart automation lower the total cost of ownership. You benefit from simplified upgrades, reduced manual intervention, and streamlined support across the revenue cycle, ensuring long-term sustainability.
04
Infrastructure-agnostic design
Our custom RCM and claim adjudication solutions are cloud-native and deployable across AWS, Azure, GCP, on-premises, or hybrid environments. This flexibility allows seamless integration with existing systems and supports strategic IT initiatives.
05
Future-ready architecture
We design RCM and claim adjudication platforms that evolve with regulatory and payer changes, using loosely coupled components and configurable rules engines. This enables easy adaptation to changing payer models, regulations, and industry standards.
06
Secure payments & compliance
We ensure HIPAA-compliant handling of health data and PCI DSS-secure payment processing. Our solutions also align with CMS and ONC regulations to support trusted, end-to-end exchange workflows for both clinical and financial data.
The logical architecture of end-to-end RCM platform we can develop for you
Patient scheduled
Patient Portal
- Self-scheduling & appointments
- Patient onboarding
- Insurance plan management
- Payment tools
Insurance check and verification
Patient Eligibility Module
- Coverage validation
- Eligibility checks
- Benefits exploration
- Coordination of benefits
- Patient matching
Insurance approval
Prior Authorization Engine
- Medical coding
- Policy rules evaluation
- Clinical criteria mapping
- Automation & smart routing
- Decision explainability
Clinical visit
Provider Portal
- EHR Integration
- Clinical documentation
- Charge capture
- Claims visibility
Submitting medical bills
Claims & Billing Processing Module
- Bill generation
- Claims creation
- Scrubbing & validation
- Submission to payer
- Claim auto-adjudication
- Denial management
- Patient billing
Matching payments with bills
Reconciliations Module
- Payment posting
- Electronic Remittance Advice (ERA) processing
- Accounts Receivable (AR) management
- Follow-ups
Reporting & Analytics
Revenue dashboards Denial rate analysis Predictive analytics (AI-based RCM insights)
Supports smarter decision-making and ensures regulatory compliance
Interoperability & Data Exchange Layer
Payer-Provider Integration HL7v2/X12/FHIR APIs ICD-10-CM, CPT, SNOMED CT, LOINC Eligibility (270/271) Claims (837) PA Requests/Responses Clinical Data Repository Integration
Enables seamless data flow and communication between all system components and external entities
Data Security and Privacy Layer
Anomaly Detection Prevention Rules Engine Identity & Access Controls External Watchlist Integration Attribution-based Access Control Data encryption in transit Data anonymization & pseudonymization Audit logs (HIPAA, CMS, ONC)
Protects revenue integrity and safeguards patient data across all RCM processes
Employ the power of FHIR data analytics for your RCM or claim adjudication solution
Use Kodjin, our ready-to-implement FHIR-driven analytics solution, to transform data into actionable insights, streamline reporting for your custom RCM systems, and develop efficient financial models.
Key considerations before starting your RCM or healthcare claim management software development
Define your revenue cycle scope
Start with a detailed understanding of your current billing lifecycle — encounters, coding, claims, remits, denials, and payments. Identify handoff points, bottlenecks, and manual steps to prioritize for automation.
Choose the right data standards and formats
Successful software solutions for medical billing depend on interoperability. Align early with standards like X12 (837, 835, 270/271, 278) and FHIR for claims, eligibility, and prior auth. Define consistent coding (ICD-10, CPT, NDC) and terminology used across systems.
Coordinate with the clearinghouses and provider systems
Ensure your platform supports varied provider submissions and pre-check logic. Early coordination with clearinghouses helps manage edge cases and reduce downstream issues.
Ensure explainability and auditability
RCM workflows must be transparent for compliance and operational review. Log decisions across claim edits, rejections, and approvals. Ensure the system supports drill-down views for auditors, finance, and support staff.
Embed rules for compliance and exception handling
Anticipate common rejection causes — coding errors, authorization gaps, eligibility mismatches — and create configurable rules to prevent them. Include workflows for appeals, manual overrides, and flagged reviews.
Plan secure payment and patient responsibility flows
Enable secure transactions, PCI DSS-compliant payment collection, and patient responsibility estimation. Support payment plans, digital invoicing, and clear balance tracking to avoid confusion and reduce bad debt.
Prepare for multi-entity billing scenarios
If your RCM platform serves multiple practices, facilities, or specialties, build in multi-tenant capabilities. Ensure flexible configurations for payer contracts, fee schedules, and custom billing rules per entity.
Test thoroughly and phase your rollout
Use production-like data to simulate full billing cycles across diverse payer mixes. Pilot with a subset of users, validate remittance and reconciliation workflows and adjust your automation rules before full-scale launch of your custom medical billing software.
Let us handle the complexities of the medical billing solutions development for you
We can manage all these intricacies so you can focus on what matters most — providing quality care.
Why choose Edenlab for medical billing software development delivery
Proven delivery framework for complex healthcare systems
We’re not just developing medical billing software — we’re delivering reliable, production-ready solutions. Our delivery approach is built on transparency, lean team structures, and automation-first practices. This ensures faster launch cycles, lower risks, and consistent product quality.
Healthcare tech complexity is our element
Our development company brings deep healthcare expertise and hands-on experience in critical projects — from national eHealth systems to enterprise-grade EHR and RCM platforms. We streamline development with compact, senior teams who take ownership, speak the customer’s language, and know healthcare standards inside out.
Cost-effective development, reasonable decisions
We cut time-to-market and lower the development budget through reusable components and automated infrastructure. Our modular approach supports predictable scaling and simplifies maintenance. This helps teams respond faster to evolving payer, regulatory, and business needs.
Explore more services and custom solutions we provide
Healthcare integration services
We connect healthcare systems and data sources to optimize workflows and data exchange. Edenlab combines industry tools with custom platforms to ensure robust integrations backed by deep expertise.
Healthcare data and analytics services
We construct infrastructure to normalize and activate your healthcare data, which enables informed decisions and operational optimization. Our solutions prepare you for AI integration and maintain data quality.
