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X12 EDI Databases for HIPAA Transactions

The X12 HIPAA transaction set is used across the healthcare industry to transmit claim, enrollment and payment information. Given the importance and ubiquity of these EDI files, you might assume that translating them from ANSI to a relational database format would be well-supported with a range of options.

In practice, a task as common as parsing a claim or encounter and storing it in a database can quickly escalate into a significant problem.

One solution we’ve seen involves archiving a snapshot of the EDI file using filestream storage. This can satisfy some retention requirements, but provides little in terms of fine-grained tracking or analytic capabilities.

A more complete approach is to parse the X12 file into its discrete elements and store them in a relational database. The ideal solution captures the full extent of the EDI transactions while also applying a reasonable leveling of flattening to keep in the number of table joins under control.

The T-Connect HIPAA Database is designed to solve this problem. The T-Connect API rapidly parses EDI files into .Net objects and persists them to SQL Server databases. T-Connect covers the full spectrum of HIPAA transactions:

X12 Databases

HIPAA EDI Databases

 

A relational model of your data presents significant opportunities to improve workflows and reduce overhead.

Tracking

A consistent issue for trading partners is tracking EDI messages as they flow through a variety of enrichment and validation processes. This report is an example of tracking 837 claims as they move through an adjudication workflow and submission to a state regulatory agency.

Claim Database Tracking

837 EDI Reporting

 

Correlation

Many of the HIPAA EDI transactions were designed for use in request / response patterns.

  • 835 remittance advice provides detail on the adjudication and payment of 837 claims
  • 837s also correlate with 277-CA (claim acknowledgments) for detailed validation information
  • 270 / 271 Eligibility Inquiry and Response
  • 276 / 277 Claim Status Request and Response
  • 999 serves as an acknowledgment to all transactions

In addition to inbounding EDI, it’s also possible to outbound ANSI files from the T-Connect databases. The strength of an RDBMS for joining data sets can provide an efficient mechanism for generating 271, 276 and 277-CA responses.

Database correlation can also produce reports that cover claim intake to payment, and provide the foundation for data warehousing. This example ties together claims, remittance advice and claim acknowledgments.

Claim to Remittance Advice Query

Joining an 837 to an 835

 

Analytics

Delivering dashboards and self-service BI models means ETL. A common benchmark laid out in Kimball’s Data Warehouse Toolkit is that developing the ETL framework – the design of staging tables, data validation, cleansing, and transformation – can consume 70-80% of the time involved in building a data warehouse.

T-Connect handles the majority of these requirements out of the box. With the immediate ability to load every element of each HIPAA transaction into a database, organizations can focus their bandwidth on developing the specific data visualizations required by their business needs.

 

HIPAA EDI Dashboard

837 Claim Dashboard

 

Enrichment

Edits or enrichment are often performed as EDI transactions move throw workflows, based on the HIPAA standard as well as specific business rules. T-Connect exposes a .Net API that allows for this capability.

We recognize that some organizations prefer to maintain enrichment logic in database procedures. There are advantages to this approach. A common lookup procedure, such as an eligibility check on claim intake, can be performed in batch if the data is arranged in a relational format.

Summary

Database persistence of the HIPAA EDI transactions is a powerful capability with many applications. Leveraging the T-Connect Databases makes these capabilities immediately accessible with minimal integration effort.

To begin a conversation with Tallan and see T-Connect in action, contact us today to discuss how we can improve your EDI management capabilities.

 

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