What is a healthcare payer?

A healthcare payer is the organization that finances and reimburses care — a health insurance company, managed-care plan, or government program such as Medicare or Medicaid — processing claims, managing member risk, and paying providers. WinFully helps payers modernize claims, unify member data over HL7/FHIR, and meet CMS interoperability mandates like CMS-0057-F while staying HIPAA-compliant.

Which EDI transactions do you support for payers?

The core X12 set — 834 (enrollment), 837/835 (claims and remittance), 270/271 (eligibility), and 278 (prior authorization) — integrated with your core administration and claims platforms.

Do you support CMS interoperability mandates like CMS-0057-F?

Yes. We implement the required FHIR APIs — Patient Access, Provider Directory, Payer-to-Payer exchange, and Prior Authorization — to meet CMS interoperability rules on deadline.

Can you help improve STARS and HEDIS performance?

Yes. We unify clinical and claims data so risk adjustment and quality measures compute accurately, closing the care gaps that drive STARS ratings and HEDIS scores.

Healthcare & Life Science

Payer (Health Insurance Companies)

Help payers transform cost, quality, and member and provider experiences with HL7/FHIR interoperability, advanced analytics, and HIPAA/HITECH compliance.

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Industry

Healthcare interoperability

Healthcare strategies

Data analytics

Generative AI

How we help

The challenge

The problems that bring teams to us

The CMS-0057-F clock

Patient, Provider, Payer-to-Payer, and Prior-Auth FHIR APIs are due — with public metrics.

Costly, slow claims

Administrative overhead and bottlenecks drag on margins and member satisfaction.

Fragmented member data

Disconnected systems make risk adjustment and STARS/HEDIS performance harder.

What we do

Connect clinical data across your platforms

Payers win at value-based care by controlling cost without spending down member and provider trust. We tighten claims processing, unify clinical data over HL7/FHIR, and keep every workflow HIPAA/HITECH-compliant, so quality scores and margins can climb together.

Healthcare interoperability

Unify clinical data over HL7 and FHIR to clear bottlenecks and improve care outcomes while keeping cost in check.

Healthcare strategies

Risk adjustment, care management, and full HEDIS strategies, built in-house, that lift STARS ratings and clinical performance.

Data analytics

Turn scattered data into insight you can act on, with data governance sound enough to support both compliance and growth.

Generative AI

Combine AI-driven analytics with real domain expertise to push value-based care forward on secure, scalable systems.

Healthcare IT consulting

Modernize infrastructure and workflows with strategies aligned to HIPAA and HITECH regulations.

Claims optimization

Tighten claims processing to cut administrative overhead and get more done with less friction.

How it works

Clinical data, flowing where it needs to go

We connect source systems, normalize to HL7 and FHIR, and route validated data to the payers, analytics, and applications that depend on it — securely and with a full audit trail.

What you get

Outcomes you can take to your board

CMS-0057-F ready

The required FHIR APIs stood up, tested, and operational ahead of the deadline.

Leaner claims

Streamlined processing that cuts administrative overhead and speeds decisions.

Better quality scores

Unified data that lifts STARS ratings and HEDIS performance.

Drive your business forward

Transform member health and reduce cost with smarter claims

Deep domain expertise and a broad healthcare toolkit let us clean up claims, strengthen data integration over HL7/FHIR, and hold the line on HIPAA/HITECH compliance. With advanced analytics running on secure infrastructure, we help you cut administrative overhead, work more efficiently, and keep raising member satisfaction.

Outcomes

Superior outcomes for members, providers, and stakeholders

We aim past the checklist. By connecting clinical data across platforms and putting advanced analytics to work, we help you deliver better outcomes for everyone in your network.

Reduced operational bottlenecks through unified clinical data
Optimized STARS ratings and HEDIS performance
Informed decisions for patients, providers, and payers
Secure, scalable solutions built for a changing landscape

CMS-0057-FFHIR APIs

HIPAA · HITECHCompliant

HL7 · FHIRInteroperability

FHIR APIs on deadline: CMS-0057-FFHIR APIs on deadline
EDI transactions: 834 · 837 · 835 · 278EDI transactions
years in Healthcare IT: 18+years in Healthcare IT

On the hook for CMS-0057-F?

Get a free readiness assessment — gap analysis, build plan, and timeline to the deadline.

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FAQ

Frequently asked questions

Explore more

Related capabilities

Providers Healthcare data exchange Healthcare security & compliance Data Analytics Enterprise Software Development

Proof

Related work

AI & ML

Transforming Public Health Data with LLM & NLP

We built a cloud-native AI/ML platform that standardizes large-scale public health data into continuously-updating health indices for clinicians and patients.

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Interoperability

FHIR and DICOM to Enable AI-Assisted Radiology Workflows

We unified fragmented PACS, RIS and HL7 systems on an HL7 FHIR and DICOM backbone so validated AI findings surface inside the radiologist's viewer and report.

Read the case study

Healthcare

Better Patient Experience Using HL7 FHIR on Cloud

We modernized a health system's oncology app onto HL7 FHIR and cloud-native infrastructure, unifying clinical and lifestyle data into one patient profile.

Read the case study

Ready to start your digital transformation?

Let's talk about your roadmap, your compliance needs, and where technology can move your business forward.