Each day health plan administrators look forward to the challenge of loading 834 enrollments and 837 claims into their adjudication systems.
From a distance, it seems simple to report and reconcile the EDI transactions submitted by providers and clearinghouses through a plan’s intake workflow. Drilling into the steps along the inbounding process, challenges emerge which can present insurmountable obstacles to answering a question as basic as: How long has this claim been held up in my intake process?
TriZetto QNXT is a common adjudication platform we’ll use to illustrate this point. In a typical workflow, loading claims might involve:
Handoff: The day’s 837s are pulled from an SFTP server and moved to the start of the intake process.
Archive: Move files into processing workflow, and archive a copy.
EDI Structural Validation – Basic checks are performed to ensure the 837 transactions are well-formed. This level of validation is…
X12 Studio provides validation capabilities that can be used to validate claims, enrollments, and other HIPAA X12 EDI file types. X12 Studio can be used to test those files by reading, validating, and producing an X12 999 Acknowledgement (ACK). The 5010 999 ACK replaced the previous version – 4010 997 ACK. The 999 ACK informs the submitter that the EDI submitted is validated according to the receiver’s implementation guide. This validation includes the results describing the quality of the functional group’s syntax. Sometimes this validation is referred to as WEDI SNIP level edits 1 and 2.
Steps to Generate the 999 ACK
To start, download X12 Studio and install the application:
Launch the application and open an existing 837I, 837P, 834, or any of the HIPAA X12 EDI files:
Click on the Generate ACK 999 icon in the top menu:
View the Output tab at…
When the Health Insurance Exchange (HIX) network went online in late 2013, the industry was challenged with reconciling new subscribers to their related premium payments and subsidies. Health plans painstakingly assembled Excel eligibility extracts to invoice their Federally Facilitated Marketplace (FFM) or State-based Exchange (SBE) for tax credit reimbursement. However, by the start of 2016, the FFM became the system of record for eligibility, and issuers were required to accept a new variant of EDI representing premium payments.
Traditionally, the 820-Payment Order / Remittance Advice transaction (005010X218) has been transmitted from payroll agencies and government healthcare organizations to insurers in order to provide summary or subscriber-level information regarding premium payments. With the advent of ACA exchanges, enough variations surfaced in this traditional handshake that a new version of the 820 was required. The HIX 820 (005010X306) removes structures unnecessary for exchange reporting, and adds tracking segments for the unique aspects of these plans, such as…
Exporting X12 837 claim files into standardized CMS1500 or UB-04 forms is simple with T-Connect X12 Studio Toolbox’s PDF Claim Form Generator. CMS1500 is the standardized form for X12 837P (Professional) EDI files. The CMS1450, aka UB-04, provides the form for 837I (Institutional). Both forms are provided by the Centers for Medicare & Medicaid Services (CMS). The PDF claim files can be used to view, archive, or manage EDI claims into a human-readable form. Our Claim Form Generator feature is a very useful tool for EDI Analysts, overlaying 837 EDI data onto industry-standardized forms.
Steps to Generate the PDF 1500CMS or UB04 Forms
To start, download X12 Studio and install the application:
Launch the application and open an existing 837I or 837P X12 EDI format:
Click on the Generate PDF icon in the top menu:
View the Output tab at the bottom of the application. This…
Ensuring that 837 EDI transactions meet validity checks is critical to improving auto-adjudication and encounter submission acceptance rates. SNIP Type 3 describes the rules for balancing header and detail levels of the Claim, Premium Payment and Remittance Advice transaction sets. Previously, our blog covered the logic required to balance 835 transactions. Now we’ll look at the steps necessary to balance claims with service lines, including Coordination of Benefits loops in multiple payer scenarios.
Claims and encounters may be represented by a variety of X12 transaction types: 837 Professional, Institutional and Dental, as well as their corresponding post-adjudicated variants (298, 299, 300), intended for submission to All-Payer Claims Databases. The following logic applies to all versions of the 837 equally, with a few caveats noted below.
Rule 1 – Balancing Claim Charge Amounts
The first claim balancing rule is straightforward: given the parent-child relationship of 2300 claim loops to their 2400 service…
An EDI software’s ability to identify and respond to invalid X12 HIPAA EDI transactions is a major contributor to the effectiveness of EDI dependent organizations. Many healthcare companies appoint a business unit as stewards of the tens of thousands of transactions that are transmitted between payers, providers, and trading partners providing auxiliary services. These business units are often hard-pressed to respond to the quantity of incorrect claims, enrollments and payments received within their current EDI solutions or products.
The T-Connect EDI Management Suite is Tallan’s healthcare EDI product, providing actionable insight, alerting, and painless mechanisms to respond to invalid X12 EDI transactions flowing in and out of the organization. The following is a brief introduction into some of these capabilities.
The EDI solution consists of several components working in unison to introduce, augment or replace an EDI processing system.
· The T-Connect Management Portal,…
Need a way to test your systems without compromising patient data? Creating Electronic Data Interchange (EDI) test files from scratch can be an extremely time-consuming option. This leaves many searching for downloadable sample files that often contain only the mandatory loops and hinder the scope of your HIPAA EDI testing.
Fortunately, today’s Healthcare EDI professionals can find an EDI Management Platform to help alleviate their HIPAA compliance headaches.
The T-Connect EDI management suite features the X12 Studio EDI Toolbox, an EDI development toolkit with a wide range of features that are essential to simplifying the EDI development process. There you’ll find the HIPAA Test File Generator which can generate various sample EDI files, for any healthcare EDI transaction type, in the blink of an eye.
This post will demonstrate how to generate EDI test files in X12 Studio EDI Toolbox
1. The process for utilizing the HIPAA Test File Generator is straightforward. To start, click on the “HIPAA Test File…
The Electronic Data Interchange (EDI) consists of a file in a specific format that represents data exchanged in a transaction from supply chain to healthcare. EDI 835 Claim Payment transaction provides payments information in reference to claims in EDI 837 Healthcare Claim format. The details include transactions such as charges, deductible, copay, payers, payee, etc. The information is stored a hierarchical structure. The standard of EDI format is well defined and the complexity can be very overwhelming. Additionally, we do not want this high degree of detail slowing our processing time.
One of the problems that enterprise systems face with EDI is file size. A single EDI 835 may contain multiple claim records and the quantity of claims in a single file can make it very difficult to process the file. Systems are often bogged down when dealing with a very…
As we strike out into 2018, the implementation of All-Payer Claims Databases (APCD) across states remains variable and dynamic. Massachusetts maintains a comprehensive implementation, aggregating data feeds from over 80 public and private payers. Massachusetts has leveraged their APCD to create a state-specific risk adjustment model to meet the ACA provision which balances funds from healthier populations to higher risk pools. Late in 2016, Minnesota concluded a feasibility study which determined their APCD could significantly improve risk adjustment vs. the federal model.
On the other hand, West Virginia and Tennessee have put APCD development on hold. California payers optionally submit claims and encounters to a public benefit corporation. Legal, fiscal and political concerns guarantee a fluid situation for insurers.
This blog post is focused on the technical obstacles that health plans face in states requiring APCD submission. Since these databases have phased in over the last decade through both voluntary and legislated…