PAYERS & REIMBURSEMENT CONNECTORS

Overview

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Integrate payer eligibility, claims, reimbursement and reconciliation workflows without turning Mediloop into a payer or payment institution.

CoverageEligibilityPrior AuthorizationClaimsTariffsAdjudicationReconciliation

Simplify Reimbursement

Automate eligibility, claims and reimbursement tracking.

Support Multiple Payers

Connect national and private payer ecosystems.

Interoperable by Design

Use FHIR, national APIs and configurable adapters.

Compliant & Secure

Keep payer workflows auditable while financial settlement remains with authorized entities.

What Are Payers & Reimbursement Connectors?

Healthcare reimbursement orchestration — not a payment gateway

Mediloop exchanges coverage, authorization, claim, adjudication and reconciliation information with payer systems. Mediloop does not become the payer, bank or financial settlement provider; authoritative payer decisions and settlement remain with regulated/authorized entities.

Key Benefits

Faster eligibility and authorization checks

Reduced administrative re-entry and manual follow-up

Traceable claim status and payer explanations

Configurable multi-payer and multi-country workflows

Clear separation between payer adjudication, payment provider settlement and Mediloop records

Operational analytics, reconciliation and exception management

End-to-End Reimbursement Workflow

Care Delivery

Consultation, prescription, procedure or hospital care

Eligibility

Verify coverage and entitlements

Authorization / Claim

Prior authorization when required; create validated claim

Adjudication

Payer applies tariffs, rules and returns decision

Payment Status

Track payer/payment-provider settlement status

Reconciliation

Match claims, decisions and payment references

Supported Payers

Payer ecosystem	Examples	Integration model	Status
Luxembourg	CNS and relevant partners	National/payer adapter	Initial focus
France	Assurance Maladie / CPAM	National/payer adapter	Initial focus
Complementary insurance	Mutuelles / private insurers	Payer-specific API / files	Adapter-based
Other national/EU payers	Country-specific systems	Configurable adapter	Future/on demand

Architecture

Mediloop Workflows

Care, pharmacy, billing and hospital processes

Payer Orchestration

Coverage, authorization, claims, status and reconciliation

Adapter Layer

CNS, CPAM, complementary insurers and national formats

Payer Systems

Authoritative coverage/adjudication endpoints

Monitoring & Audit

Correlation, retries, exceptions and reporting

APIs & Standards

Surface	Examples	Role
FHIR financial resources	Coverage, Claim, ClaimResponse, ExplanationOfBenefit	Interoperable healthcare financial data where applicable
Payer/national APIs	Eligibility, prior authorization, claims/status	Country/payer-specific operations
EDI / secure files	X12/EDIFACT/CSV/SFTP where required	Legacy/batch payer exchange
Events/webhooks	claim.status.changed, payment.status.changed	Async workflow updates

Key Entities

Coverage

Patient coverage, plan, validity and benefits.

Claim

Billable healthcare service submission.

Claim Response

Payer decision, amounts and explanations.

Reconciliation Record

Expected vs received amounts and exception state.

Developer Integration Surface

Surface	Operation / resource	Use	Status
FHIR	Coverage / Claim / ClaimResponse / EOB	Standard financial resource exchange	FHIR where applicable
Payer API	eligibility / authorize / submit / status	Payer workflow	Country-specific
Batch/EDI	SFTP / EDI formats	Legacy/bulk exchange	Payer-specific
Events	status / adjudication / reconciliation	Async integration	Planned/evolving
SDK	Payer workflow helpers	Developer productivity	Published versions only

Next Steps

Identify payer ecosystem and use case

Review legal/contractual onboarding

Implement coverage first

Add authorization/claims with payer-specific validation

Build reconciliation and monitoring before go-live