We apply AI-powered automation and deep technical expertise to the systems healthcare organizations depend on — EDI pipelines, FHIR APIs, and intelligent workflows built for compliance, operational scale, and long-term maintainability.
CMS-0057-F — Interoperability & Prior Authorization Rule
CMS-0057-F requires Medicare Advantage plans, Medicaid managed care organizations, CHIP programs, and qualified health plans to implement FHIR R4 APIs for prior authorization, provider access, and payer-to-payer data exchange. Non-compliance carries public reporting obligations and significant operational risk.
What We Do
We work where the real complexity lives — between systems, across teams, and inside workflows that were never designed to scale. No over-engineered platforms. No vendor lock-in. Systems your team can own.
Healthcare organizations are processing millions of transactions through human queues that AI-powered pipelines should own — eligibility checks, auth submissions, claims routing, and enrollment updates handled manually when they don't have to be.
Let's talk about your workflowsWe apply AI and intelligent automation to the highest-volume, most repetitive workflows in healthcare administration. From 270/271 eligibility verification to 278 prior authorization routing, 837 claim scrubbing to 834 enrollment management — we build AI-powered pipelines that handle the routine, learn from exceptions, and escalate only what genuinely needs human judgment.
Beyond transaction automation, we bring AI to provider data quality — cleansing, enriching, and maintaining golden records that downstream systems depend on. Denial pattern analysis, claims scrubbing, and auth classification use machine learning to improve accuracy over time, not just automate what you're already doing wrong faster.
A compliance gap you don't know about isn't neutral — it's a risk waiting for a trigger. Audits, incidents, and regulatory changes don't wait for you to be ready.
Schedule a risk conversationHealthcare data environments carry compounding risk — PHI distributed across systems, accessed by many roles, governed by HIPAA, HITECH, and now expanding CMS interoperability mandates. Most organizations have some controls in place but lack confidence they're applied consistently, or that an audit or breach would be manageable. We close those gaps methodically: not by layering tools, but by understanding how data actually moves through your environment and building controls that fit it.
This covers role-based access design, encryption-at-rest configuration, PHI de-identification for development environments, and full audit trail coverage across every data-touching system. We also help teams prepare for regulatory audits, document their posture, and build incident response runbooks before they're ever needed.
Your systems have the data. The problem is none of them agree on how to share it — and the gaps between them are where revenue leaks and errors hide.
Map your integration gapsMost healthcare organizations don't lack data — they lack reliable pipes between systems. Claims sitting in clearinghouse queues, eligibility checks timing out silently, EHR data stranded in proprietary formats, provider rosters nobody trusts because they haven't synced in months. We design integration architectures that are durable, observable, and built to recover gracefully when something breaks — because in healthcare, something always eventually breaks.
Whether it's a single API connection between your care management platform and a payer, or a multi-party EDI exchange touching clearinghouses, providers, and internal systems — we spec the data contracts, build the transformation layer, configure the transport, and set up monitoring before handoff. Every integration includes runbooks for the most common failure scenarios so your team isn't guessing at 2 AM.
CMS-0057-F isn't optional. The question is whether you build it right the first time — or rebuild it after the January 2027 deadline under pressure.
Start your gap assessmentFHIR R4 implementation is not just a technical project — it requires understanding the regulatory requirements of CMS-0057-F, the FHIR data model, and how your existing EDI infrastructure (278 prior auths, 835/837 claims) maps to the new API layer. Organizations that treat it purely as a dev task often end up with a technically functional API that doesn't satisfy the rule. We bring experience in both the technical standards and the operational realities of healthcare IT.
We start with a structured gap assessment against CMS-0057-F requirements specific to your organization type — Medicare Advantage, Medicaid MCO, CHIP, or QHP. From there, we deliver a phased implementation roadmap, build and connect the required APIs to your source systems, and run conformance testing before go-live. Post-launch, your internal team gets the documentation to own ongoing maintenance.
Who We Serve
We've worked with every participant in the healthcare data ecosystem — and we understand the distinct technical and compliance pressures each one faces.
Our Approach
We don't show up with a pre-packaged solution. We start by understanding how your teams actually operate — then design and deliver systems they can own independently.
We start by forgetting everything we assume about how your operation should work — and asking your team what actually happens on a normal Tuesday.
Most engagements reveal a gap between the documented process and the real one. Staff have built workarounds. Systems have undocumented quirks. Manual steps fill the cracks that integrations were supposed to close. We find all of it before we propose anything — because a solution built on the wrong picture of the problem will fail in the same places the old one did.
We conduct separate working sessions with operations, clinical, and IT teams — not a joint kickoff where nobody says what they really think. We map actual data flows, trace every handoff, and document every manual step and exception your team handles daily.
No surprises. You see the full architecture, the tradeoffs, and the effort before we write a single line of code — and you get a say in every major decision.
We design solutions matched to your actual constraints — team size, budget, existing systems, risk tolerance, and timeline. We don't design for an ideal future state that requires replacing everything. We design for what can be built on what you have, in the time you have, by people who will need to maintain it.
For high-stakes decisions, we present 2–3 approaches with honest tradeoffs rather than a single recommendation we're attached to. You get a written implementation plan that both your leadership and your technical teams can read — not a slide deck and not a 200-page spec.
You own it when we're done. Not dependent on us. Not a black box. A system your team understands, operates, and can extend without calling us first.
We build in testable, incremental phases — not a big-bang launch that risks everything at once. Each phase delivers something working that your team can validate before we proceed. Edge cases, error handling, and failure modes are designed explicitly, not discovered in production.
Before we hand off, we run operational knowledge transfer with the people who will own the system day-to-day. They know what every component does, what to do when it fails, and where to look when something unexpected happens. That documentation stays with you — complete, readable, and maintained.
About Primex Systems
Primex Systems is a specialized healthcare technology consulting firm focused on one thing: helping organizations make their healthcare data systems work the way they're supposed to.
We work alongside health plans, providers, clearinghouses, and managed care organizations to help plan, build, and integrate the systems that drive their operations — prior authorization workflows, EDI transaction pipelines, FHIR APIs, and the compliance infrastructure behind them.
Engagements are kept small and focused. You work directly with senior consultants who have lived in these domains — not a project manager who hands work off downstream. We embed with your team, learn your constraints, and help build solutions your people can own and maintain long after we're gone.
Get Started
Book a free 30-minute intro call. We'll discuss where you are, where you need to be by 2027, and what a practical path forward looks like for your organization.
Book a 30-Min Intro CallNo sales pitch. Just an honest conversation about your needs. · hello@primexsystems.org
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Healthcare data is sensitive, your workflows are complex, and your trust is earned — not assumed. Every conversation starts with listening, not selling.