Edifecs Named Top-Tier Software Vendor by APPS RUN THE WORLD in the APPS TOP 500 Market Report

Edifecs Strengths, Domain Expertise, and Key Differentiators

Edifecs is a leading healthcare technology firm committed to enhancing healthcare outcomes, lowering costs, and fostering innovation by optimizing the entire process of patient data exchange, thereby enhancing overall healthcare efficiency. This mission underscores the company's dedication to driving positive impacts within the healthcare industry through streamlined processes and improved interoperability.

Edifecs Recent Developments

February 2025, Edifecs launched of its Healthcare Interoperability Cloud. This solution enables payers to adopt a strategic approach to interoperability while addressing compliance requirements, including CMS-9115-F and CMS-0057-F, as well as non-compliance use cases. A recent study conducted by a leading third-party consultant, which analyzed 99 payers, identified Edifecs as the leading partner for both FHIR® and EDI solutions. This recognition uniquely positions the company as the preferred provider of strategic interoperability capabilities for healthcare payers. Since its establishment in 1996, Edifecs has played a pivotal role in defining the standards that govern interoperability.

In September 2024, Edifecs announced its new product, Concurrent Risk Adjustment (CRA). CRA helps Managed Care Organizations (MCOs) and payers serving other at-risk markets to intervene earlier in the risk adjustment process by sharing previously documented chronic conditions with providers. With CRA, organizations can drive more complete and accurate documentation and coding prior to claim submission and support better health outcomes for their members.

Edifecs introduced a solution aimed at automating prior authorization processes at the point of care, integrating with electronic health records and utilizing artificial intelligence, natural language processing, and Fast Healthcare Interoperability Resources (FHIR) standards. The offering includes payer prior authorization management workflows with tracking, monitoring, and reporting, and connects with utilization management systems and clinical guideline repositories. It supports EHR-agnostic integration, drawing from numerous payer implementations for patient access. Additionally, through the acquisitions of Talix and Health Fidelity, Edifecs incorporated their NLP and AI technologies into its Encounter Management solution, supporting risk adjustment processes for Medicare Advantage, Managed Medicaid, and Affordable Care Act products.

Edifecs Mergers and Acquisitions (M&A) Activities

In February 2025, Cotiviti, a leader in data-driven healthcare solutions, has entered into an agreement to acquire Edifecs. The combined platform will enhance connectivity between payers and providers, enable increased collaboration in the delivery of care, and accelerate deployment of value-added solutions in the healthcare system. Operating under the Cotiviti brand, clients of the combined organization can accelerate key business objectives while achieving meaningful improvements in efficiency and quality of care. Emad Rizk, M.D., Chairman, President, and CEO of Cotiviti will lead the combined company in the same capacity.

In December 2021, Edifecs concluded the acquisition of Health Fidelity, a prominent provider of risk adjustment solutions. This strategic integration positions Edifecs to deliver industry-leading Natural Language Processing (NLP), workflow, and submissions solutions, significantly augmenting suspecting and financial analytics capabilities for its customers. The enriched portfolio ensures a seamless solution, eliminating the need for customers to incur expenses related to intricate integrations and multi-vendor management overhead.

In September 2021, Edifecs acquired Talix, an esteemed information technology company specializing in risk and quality solutions for healthcare payers and providers. The strategic integration of Edifecs' and Talix's technologies resulted in an enhanced risk adjustment solution. The synergistic blend of workflows and insights that derive from both entities significantly enhances operational efficiencies and fosters direct collaboration between payers and providers.

Edifecs Customers in ARTW Customer Database

Leveraging a rigorous data-centric research methodology, APPS RUN THE WORLD asks the simple question: Who’s buying Edifecs applications and why? And we provide the answers – supported by decades of research – to our clients around the world. Our Customer database has over 100 data fields that detail company usage of Edifecs and other enterprise apps by function, customer size, industry, location, implementation status, partner involvement, Line of Business Key Stakeholders and IT decision makers contact details. List of Verified Edifecs customers.

Edifecs Key Enterprise and Cloud Applications

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Edifecs Direct vs Indirect sales

Edifecs Customers - Breakdown by Geo, Size, Vertical and Product

List of Verified Edifecs Customers

No. of Edifecs Customers: 400

No. of Edifecs Enterprise Applications Customers: 300 Millions

No. of Edifecs Cloud Customers: x

No. of Edifecs Cloud Subscribers: x

Edifecs serves over 400 customers, including 350 in the healthcare sector and 50 in non-healthcare industries across international markets. Its client base includes 70 provider organizations in 23 U.S. states and spans health payers, providers, government agencies, and industries such as transportation, retail, financial services, and manufacturing. The company works with 25 of the 37 Blue Cross Blue Shield licensees and maintains contracts with various State Medicaid programs and the Centers for Medicare and Medicaid Services. Clients include Centene Corporation, ClearConnect, Humana, MultiPlan, and others.

Edifecs Market Opportunities, M&A and Geo Expansions

Edifecs has expanded its strategic collaborations to improve data exchange and support value-based care models within the healthcare sector. Through its partnership with HealthEdge, Edifecs integrated its EDI Gateway with the HealthRules Payer claims adjudication system. This integration is intended to simplify data connectivity for payers, reduce implementation timelines, and lower ongoing maintenance costs associated with custom or internally developed systems. The arrangement also aims to improve access and control over claims data across the transaction lifecycle for mutual clients.

In a separate initiative, Edifecs partnered with 3M Health Information Systems to deliver an integrated solution that combines Edifecs’ value-based payment templates and risk intelligence with 3M’s patient classification tools. This offering supports payers and providers in navigating the shift to alternative payment models by enabling more accurate measurement of care outcomes and allocation of financial responsibility. During this period, Edifecs also restructured its executive leadership team, appointing new roles across product, finance, revenue, and sales functions to align with evolving organizational priorities and operational demands.

Edifecs Risks and Challenges

The company's geographical and sectoral limitations pose significant risks to its organizational development and expansion into international markets. Expanding into new markets or launching new products requires effective execution to avoid operational inefficiencies.

Edifecs Ecosystem, Partners, Resellers and SI

Edifecs has entered multiple collaborations to expand its capabilities in automated prior authorization and value-based care enablement across the healthcare ecosystem. Through its partnership with VirtualHealth, Edifecs integrated its automated prior authorization solution into the HELIOS platform to address administrative inefficiencies for healthcare payers and providers, targeting commercial health plans, ACOs, home health agencies, and healthcare systems. A separate collaboration with Empowered-Home incorporated Edifecs’ prior authorization solution into a broader ecosystem focused on virtual care management, in conjunction with clinical decision support technology from Privis Health. This initiative aims to support entities such as ACOs, IPAs, and medical groups as they adapt to remote, value-driven healthcare delivery models.

In another partnership, Edifecs joined with 3M Health Information Systems to combine actuarial and classification tools that support the implementation of Value-Based Payment models. This joint approach merges Edifecs’ risk intelligence and VBP templates with 3M’s patient classification technologies, creating a framework intended to quantify outcomes, allocate accountability, and overcome structural barriers to VBP adoption. Edifecs maintains its headquarters in Bellevue, Washington, with regional offices in Atlanta, San Francisco, and Pittsburgh, and engineering hubs in India, Moldova, Belarus, and Ukraine.

Research Methodology

Data used in research reports are derived from publicly available documents, continuous surveys of applications vendors, customers, resellers, Independent Software Vendors, systems integrators and other verifiable sources.

Vendor shares and market forecast results are based on a combination of existing databases as well as demand side and supply side research conducted throughout the year with validation from vendors, customers, channel partners and documentations such as earnings releases and 10Q and 10K filings, vertical industry studies, regional and country-level statistics from public and private institutions(i.e. colleges, universities, government agencies and trade associations).

For additional information on our methodologies, here's the link: