Case Study – EDI P&C Claims System

EDI 837, EDI 835 Batch Claims Process with PilotFish Platform

EDI Claims System Modernization End-to-End in Under
a Year!

Industrywide, P&C insurers recognize the need to modernize technology infrastructure to improve profit margins. This leading P&C insurance carrier embarked on a large-scale effort to modernize its claims management system. Critically unsupported and dated legacy EDI solutions demanded the replacement of claims integration end-to-end with robust EDI functionality on an accelerated schedule. The firm partnered with PilotFish Integration Solutions for industry-leading EDI technology and deep EDI expertise in this critical project.


The client is a leading top-tier commercial and individual Property and Casualty (P&C) carrier. The company processes a huge (and rising) volume of claims associated with P&C insurance, broadly including liability, auto, group health, homeowners and other lines of business. The firm was determined to accelerate its digital journey to streamline processes that would expedite settlement and improve profitability. To that end, the modernization and automation of the company’s claims management system end-to-end was the highest priority and included replacing current systems. Moreover, the modernized claims management system must be auditable, traceable, configurable and secure.


The company challenged its IT leadership to demonstrate the best and fastest payback on its investment in modernizing claims and billing processes. The search was for a single integration solution to improve the claims handling process by driving productivity and informing decisions that contribute to the swift, cost-effective closure of claims. 

The new platform had to deliver industry-leading claims integration experience and deep expertise in the insurance industry. The pressing challenge was the replacement of both dated and unsupported legacy integration solutions. The company had a one-year can’t-miss deadline for replacement with an advanced fully integrated platform with all the functionality needed for adjusting end-to-end claims.

Advanced, robust X12 EDI integration capabilities were a foremost requirement as many P&C policies carry a medical expense reimbursement as part of the coverage. This includes the ability to accept and transform EDI transactions for electronic billing and all the related HIPAA transaction sets. 

After an extensive review of leading integration solutions, the selection was narrowed down to PilotFish competing head-to-head with a single competitor. PilotFish’s superior EDI expertise and unmatched built-in EDI functionality won the engagement and confidence that the critical deadline would be met.


The PilotFish suite of integration products enables the integration of anything to anything anywhere –regardless of operating systems, databases, data formats, communications protocols and security programs. 

The clients processed remarkably high volumes of primarily claims transactions on a daily, weekly and monthly basis (both batch and real-time) that flowed in from an array of clearinghouses and other sources. Processing EDI 837, 835, 275, 270/271 and 276/277 transactions accurately within complex workflows presented huge hurdles. Batch transactions were received in Amazon S3 buckets, while real-time transactions arrived as embedded EDI data in a SOAP XML message. Since PilotFish is data, environment and process agnostic, none of these factors presented major impediments to moving forward fast.


EDI 837, EDI 835 Batch Claims Process with PilotFish Platform

EDI Batch Workflow with PilotFish Platform

A batch workflow showing EDI 837 Professional Healthcare Claim from a Trading Partner, ingested and traversing through the PilotFish eiPlatform SNIP Validation Processor and into an Internal DB which generates an EDI 999 Acknowledgement and an EDI 277 Claims Status Notice. The EDI 275 Patient Information Transaction and EDI 835 Claim Payment from the Trading Partner’s Source System is ingested by the PilotFish eiPlatform as an individual bill with saved attachments and payments and then transported as a JSON inquiry to the database which yields supporting info during data processing.


Insurance EDI Claim Integration Workflow with PilotFish

EDI Real-time Workflow with PilotFish Platform

A real-time workflow showing EDI 270 Eligibility Inquiry from a Trading Partner, ingested into then traversing through the PilotFish eiPlatform SNIP Validation Processor and into an Internal DB which generates an EDI 271 Eligibility Response. The EDI 276 Claims Status Inquiry from Trading Partners Source System is ingested and transformed by the PilotFish eiPlatform into a JSON API Inquiry for Eligibility and Claims Status into a Database with the JSON API Response for Eligibility and Claims Status traversing through PilotFish and transforming into a EDI 277 Claims Status Response. The EDI 999 is the Implementation Acknowledgement transaction responds to inbound transactions for both EDI 270 and EDI 276.


Designed for ease-of-use and high efficiency, PilotFish’s unique graphical point-click-drag-and-drop Automated Assembly Line approach and visual Data Mapper configure all integrations using the same consistent methodology. Each stage of the Automated Assembly Line has a drop-down list of configurable options. Users simply selected the source of the data, connectivity to the source, routing and the connectivity and data format consumable by the target. All incoming data is automatically transformed into an XML representation so that a single open-source W3C language, XSLT, can be used to transform the data.  

In transforming its claims systems, the client relied on PilotFish’s built-in components for X12 EDI and PilotFish’s comprehensive knowledge of X12 schemas and standards. They quickly confirmed in a demanding environment that PilotFish delivered the most comprehensive and innovative support of any product on the market for EDI and SNIP Levels 1-7.  

With PilotFish, SNIP Levels 1-7 are validated via its stand-alone rules-driven EDI SNIP Validation Processor. Rules generated from X12 documentation operate within the EDI Validation Processor, a highly scalable and customizable multi-threaded framework for executing validation rules and external code set testing. The process identified or fixed errors, incorrect values and incorrect usages. Unknown segments and data were captured for subsequent conversion and manipulation to facilitate multiple tries.

Validations ensured that the files met the structural standards laid out by X12 and beyond by validating specifics, such as if sets of codes are updated on a regular basis or what fields also must be present. Necessary or missing data could then be automatically inserted. Adding SNIP Level 5 supported easier generation of EDI 277 Claims Acknowledgements after EDI 837 Claims were received. PilotFish’s innovative EDI integration enabled customized rules for SNIP 6 and 7 services making it easier to meet requirements and requests from stakeholders and external partners.

PilotFish EDI validation and XML transformation immediately provided standardized and structured formats for internal and external downstream processing and far greater interoperability.

In short order, claims processing achieved a considerable advantage with PilotFish’s X12 Validation Processor and the parallel processing of thousands of validation rules at record speeds.

Support for non-EDI formats presented no problem as PilotFish’s any-to-any data transformation capabilities and protocols supported all file-based integration scenarios.

Meeting critical benchmarks, the team was well on the way to replacing the current systems with the PilotFish integration engine’s built-in capabilities for incoming data validation and translation, outgoing transaction construction, acknowledgment generation, process orchestration and scheduling. 

While the challenges were significant, the collaborative effort between the focused client IT team and PilotFish exploited the advantages of being a small team with direct communication lines. As soon as a problem arose, the partnership came up with a solution and moved forward. Mutual respect and no finger-pointing ruled, especially as it came down to the deadline to pull the switch.  Successful system replacement in record time, realizing and demonstrating cost and time savings, wowed management at all levels.


As the client’s team experienced and realized more and more what PilotFish could do and solve, they secured IT management approval to collaborate with PilotFish’s solution architects to solve problems or create solutions leveraging PilotFish’s complete product offering. 

Again and again, PilotFish understood a need or problem, dissected it and brought to bear the core competencies needed to succeed and move on.

For example, utilizing the PilotFish framework of XML, highly useful dynamic PDFs were generated for underwriters and adjusters that filtered out only relevant data for decisions. PilotFish’s customizing process turned raw data into a PDF visually useful for the people managing the claims behind the scenes. 

Here, leveraging sophisticated architecture and built-in PilotFish capabilities quickly improved claims handling and informed decisions that contributed to the swift, cost-effective closure of claims.

In modernizing, the client leveraged PilotFish’s Docker support to push and pull Docker images at will for new builds via Amazon S3.

On the operational front, management was blown away by the advantages realized with the PilotFish eiDashboard that allowed capturing new significant amounts of data coming through on transactions and reporting on them in a variety of different ways that supported the demanding needs of the day-to-day operational support for critical workflows. The eiDashboard’s ease-of-use allowed tracking of key attributes and what was happening in real-time utilizing drop-downs, custom search and filtering functionalities. Custom reports could now be generated with alacrity in order to see important data in more useful ways and take action.

Resources of all types at PilotFish proved to be scaled up and down easily. The PilotFish architecture proved flexible, scalable and infinitely extensible in action. Financially, On-Demand Licensing was advantageous for the client’s mix of batch and real-time processing from a cost perspective as it is usage-based.

In assessing the benefits and cost-effectiveness of PilotFish’s Integration Solution and engagement, the client emphasized that a huge part of what made successful replacement possible in less than a year was exactly PilotFish’s ability to assemble a team of the right people to put the right effort towards the right problem. Simply put, PilotFish had the architecture, the technology and the people critical to success in its role as a strategic partner.

Since its founding in 2001, PilotFish has been solely focused on the development of software products that enable the integration of systems, applications, equipment and devices. Billions of bits of data transverse through PilotFish software connecting virtually every kind of entity in healthcare, 90% of the top insurers, financial service companies, a wide range of manufacturers, as well as governments and their agencies. PilotFish distributes Product Licenses and delivers services directly to end users, solution providers and Value-Added Resellers across multiple industries to address a broad spectrum of integration requirements.

PilotFish will reduce your upfront investment, deliver more value and generate a higher ROI. Give us a call at 860 632 9900 or click the button.

X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.

This is a unique website which will require a more modern browser to work! Please upgrade today!