Epic Payer Platform (EPP) Staffing Support

Key goals of EPP include:

• Enabling real-time exchange of clinical and administrative data
• Automating prior authorization and care coordination workflows
• Streamlining data access for both payer and provider teams
• Ensuring regulatory compliance and protecting patient data privacy

Core Components of the Epic Payer Platform include:

• Claims Exchange: Payers gain a broader view of services provided to members through shared claims data, helping with adjudication and care coordination.
• Clinical Document Exchange (aka Clinical Data Exchange): Facilitates the automatic sharing of clinical records between providers and payers to support value-based care models.
• Member Insights: Allows a provider’s Epic system to retrieve valuable payer-held data on a patient in real time—before a visit, for specific populations, or during an appointment—to close care gaps or guide treatment decisions.
• Prior Authorization: Automates the submission and evaluation of prior auth requests. Payers can auto-adjudicate or send approvals/denials through an Epic-native workflow, reducing delays and improving outcomes.
• ADT Event Notes: Sends automated notifications and triggers when a member is admitted, transferred, or discharged. This allows for faster transitional care and reduces manual communications between payers and providers.

Related Epic Modules Supporting EPP Functionality:

➡️ Epic Tapestry: Comprehensive managed care administration module that supports health plan operations, including claim adjudication (AP Claims), contract management, enrollment and eligibility, and referrals.

➡️ Benefits Engine: Configures intricate benefit structures, adjudication logic, and reimbursement rules to ensure accurate claims processing aligned with complex payer agreements.

➡️ Epic CRM (Customer Relationship Management): Facilitates payer-provider interaction, automating member and provider communications, referrals workflows, and managing authorization processes.

➡️ Triplets (SER, VEN, EAF): Master files that define provider, vendor, and location relationships, critical for accurate claims processing and remittance advice.

➡️ EpicCare Link & Healthy Planet: Facilitate real-time clinical data exchange, ADT notifications, care-gap closure, and clinical document sharing for population health and quality management.

Cook Children’s Health Care System – Epic Tapestry (AP Claims, CRM, Benefits Engine)

HealthTECH provided a highly experienced Epic Tapestry consultant for Cook Children’s health plan operations. This analyst, with 17 years of Epic implementation experience, specifically delivered:

• Advanced configuration of Tapestry Accounts Payable Claims and complex CRM integrations.
• Extensive Benefits Engine build and optimization, including detailed analysis and resolution of vendor contract and claims pricing issues.
• Comprehensive support for referrals claim matching, pend code management, and referral authorization integration.
• Post-migration configuration stabilization, significantly reducing operational risks and ensuring a smooth transition.

Hoag Hospital – Epic Tapestry (Triplets and Benefits Engine Analysts)

HealthTECH provided two critical Tapestry resources at Hoag Hospital to meet tight go-live deadlines:

• Epic Tapestry Triplets Analyst: Configured complex provider (SER), vendor (VEN), and facility (EAF) master files, directly enabling accurate claims adjudication and seamless integration with remittance (835) processes. This analyst had robust managed-care expertise, deep system troubleshooting skills, and proficiency in managing integrated claims workflows.
• Epic Benefits Engine Analyst: Delivered specialized benefit configuration expertise, building sophisticated benefit packages, component groups, and reimbursement formulas within Epic’s Benefits Engine. Additionally, they provided SQL-based analytics, claims adjudication troubleshooting, and advanced reporting via Power BI, markedly improving data accuracy and operational efficiency.

Together, these placements ensured Hoag’s successful go-live and long-term operational stability, highlighting HealthTECH’s ability to provide precisely matched talent for high-stakes implementations.