NPHIES Overview¶

NPHIES (National Platform for Health and Insurance Exchange Services) is the national platform enabling:

• Claim exchange
• Eligibility checks
• e-Authorizations
• Payment reconciliation

It uses FHIR R4 as the base standard.

Required Profiles¶

• Claim
• Coverage
• ExplanationOfBenefit
• Encounter
• Observation
• Procedure

FHIR Validation¶

A single failed field can reject the entire claim.

Cloudpital + BrainSAIT NPHIES Solution¶

Cloudpital provides NPHIES-certified EMR and RCM capabilities, while BrainSAIT adds AI-powered intelligence for claim optimization and automation.

Unified Architecture¶

graph TB
    subgraph "Cloudpital Platform"
        A[EMR Module]
        B[RCM Module]
        C[NPHIES Gateway]
    end

    subgraph "BrainSAIT AI Layer"
        D[ClaimLinc<br/>Validation]
        E[PolicyLinc<br/>Eligibility]
        F[DocsLinc<br/>Documents]
    end

    subgraph "NPHIES Platform"
        G[Eligibility API]
        H[Pre-Auth API]
        I[Claims API]
    end

    A -->|Encounter Data| D
    B -->|Draft Claims| D
    D -->|Validated Claims| C
    C -->|FHIR Bundle| I

    A -->|Patient Insurance| E
    E -->|Coverage Check| C
    C -->|Eligibility Request| G

    A -->|Clinical Docs| F
    F -->|FHIR Documents| C
    C -->|Attachments| H

Integration Benefits¶

Key Capabilities¶

1. Pre-Submission Validation - ClaimLinc validates all FHIR resources before submission
2. Real-Time Eligibility - PolicyLinc enhances Cloudpital's eligibility with AI predictions
3. Document Intelligence - DocsLinc extracts clinical data for NPHIES attachments
4. Denial Prevention - Predictive analytics identify issues before submission
5. Automated Resubmission - Intelligent correction and auto-retry for denials

Getting Started¶

See the comprehensive Cloudpital NPHIES Integration Guide for: - Detailed API workflows - FHIR resource examples - BrainSAIT integration code - Best practices and troubleshooting