CMS-0057-F Compliance
Without Replacing Your
Core Admin System
Meet the CMS interoperability mandate on your existing QNXT, Facets, or HealthEdge platform.
Augment now. Modernize at your pace. Replace later — only if you want to.
Four product lines.
One platform.
Cloud Health Office engages customers across four complementary product lines, each a coherent offering on its own, each connecting naturally to the next. Enter at any line and expand over time.
Public Tools
Free utilities. No signup.
Fee schedule lookup and free-tier claims repricing. Verify the calculation engines before any commercial conversation begins.
Transactional Services
Per-call APIs. Self-serve subscription.
Claims Repricing API and Pricing API for developers, billing companies, TPAs, and integrators. Free tier flows to paid tier on usage.
Managed Data Services
Subscription data. Recurring value.
State Medicaid compliance updates, CMS fee schedule updates, provider verification, terminology mapping. Healthcare data that changes constantly — tracked for you.
Platform Engagement
Payer-scale. Priced PMPM.
Multi-year relationships priced per member per month, across three layers: Compliance Accelerator, Progressive Modernization, and Full CAPS Platform.
See POSITIONING.md for the canonical four-product-line framing.
Three layers.
One Platform Engagement.
Within Platform Engagement, Cloud Health Office engages customers at three layers, each a coherent product on its own, each containing the previous. Meet us where you are — expand when you’re ready.
Layer 1 — Compliance Accelerator
Meet CMS-0057-F without replacing your core.
Production-ready FHIR surface deployable alongside your existing QNXT, HealthEdge, or Facets. Weeks to deploy.
Layer 2 — Progressive Modernization
Replace your legacy core, one domain at a time.
The strangler-fig path — your system of record stays stable while Cloud Health Office takes over appeals, then capitation, then claims, at your pace. Appeals shipped and validated.
Layer 3 — Full CAPS Platform
End-to-end cloud-native claims administration.
36 services, 9 engines, Argo-orchestrated adjudication, full X12 EDI. For new entrants today; for established payers, the milestone after Layer 2.
Not sure where to start? See POSITIONING.md for the three-layer model in detail.
Claims Work Queues — NCCI/MUE edits, prior auth, COB, provider contracting, and medical review. The Sentinel v4.0.0
Vulnerabilities
Deployment
Across 44 Projects
Modernize now.
Replace later.
A compliance and modernization layer that works alongside your legacy core admin system — delivering CMS-0057-F readiness, FHIR R4, and EDI automation without replatforming.
CMS-0057-F Compliance
Complete compliance with the CMS Interoperability and Prior Authorization Rule — 18 months ahead of the January 2027 deadline. Zero external dependencies.
Multi-Clearinghouse EDI
Native connectors for Availity, Change Healthcare, Optum, and Inovalon. Failover capability, zero vendor lock-in, and full business continuity.
X12 to FHIR R4 Transformation
Automated transformation of X12 EDI transactions (270/837/278/835) to FHIR R4 resources. Real-time, bidirectional, production-tested at scale.
Legacy Core Augmentation
Sits alongside QNXT, Facets, HealthEdge, or Amisys. Reads from your existing system, exposes FHIR R4 APIs — without touching your core operations.
HIPAA-Grade Security
BAA included. Zero known vulnerabilities. End-to-end encryption. Production-ready audit trails and compliance reporting — out of the box.
Flexible Deployment
Kubernetes-native architecture with Argo Workflows on AKS, EKS, or GKE. Container-based microservices with full infrastructure ownership. Deploy to your own subscription.
Premium Billing & ACH
Automated monthly premium invoicing with NACHA/ACH file generation, EFT draft lifecycle management, and Stripe ACH integration. Batch billing runs with sponsor-level invoicing and return processing.
Compliant. 18 Months Early.
The January 2027 deadline is not a future problem. It was solved in production, now.
Transform X12 EDI (270/837/278/835) to FHIR R4 with zero external dependencies.
2,800 comprehensive tests across 44 test projects. v4.0.0 production-ready.
Real outcomes.
Anonymized. Specific.
Health plans don’t announce wins. The numbers tell the story.
CMS Compliance Without a Core Upgrade
Regional Medicaid MCO needed CMS-0057-F compliance without an 18-month core platform replatform. Deployed in 3 weeks. Live in production with zero disruption.
- Avoided $2M+ core platform upgrade cost
- Live 18 months before the CMS deadline
- Zero impact to existing claim operations
Multi-Clearinghouse Resilience
Health plan dependent on a single clearinghouse added secondary failover capability. Zero transactions lost during a major clearinghouse outage.
- Secondary clearinghouse live in under 1 week
- Eliminated single point of operational failure
- Reduced EDI vendor dependency risk
BPaaS Exit to Internal Control
Medicare Advantage plan exiting a BPaaS vendor needed internal operations capability within 6 months. Delivered ahead of schedule with full audit trail.
- Full ownership of integration infrastructure
- Predictable Azure infrastructure costs
- Internal team fully operational within 90 days
Full Claims Pipeline.
When you’re ready for it.
Start with CMS-0057-F compliance as a layer on your legacy system. Over time, activate modular claims adjudication, benefit engines, and more — at your pace.
One platform.
Any cloud.
Kubernetes-native architecture with Argo Workflows. Deploy on any cloud or on-premise with full infrastructure control.
Kubernetes with Argo Workflows
Best for: Enterprise control, cloud independence, production-grade orchestration
- Deploy on Azure AKS, AWS EKS, or GCP GKE
- Argo Workflows for Kubernetes-native orchestration
- Full infrastructure ownership and control
- Container-based microservices architecture
- Hybrid and on-premise capable
- BSL 1.1 — bring your own environment
Complete FHIR R4, EDI, and compliance capabilities on any Kubernetes cluster.
Built by people who’ve shipped
50+ payer implementations.
Cloud Health Office was created by a team with 25+ years of combined experience building and implementing core administration platforms at Medicaid MCOs, Medicare Advantage plans, and commercial payers. We built this because we’ve watched health plans spend $2M+ and wait 18 months for integrations that should take weeks.
Deep expertise in health plan core administration platform implementations across all major platforms.
Production integrations with every major clearinghouse in the healthcare market.
HIPAA, CMS-0057-F, ACA, and state-level regulatory implementations at enterprise scale.
Azure-native, Kubernetes-first architecture designed for production health plan operations.
Now accepting pilot deployments for select health plans in 2026.
Meet CMS-0057-F on your
existing core admin system.
For Medicaid MCOs, Medicare Advantage, and commercial payers running QNXT, Facets, HealthEdge, or legacy platforms.
Compliance in weeks. Modernization on your timeline. Full replacement only if you choose it.
Questions? Email sales@cloudhealthoffice.com