Jul 19, 2021 Admin

EDI Service Provider

Benefit From Rendering EDI Outsourcing Services for Healthcare Claim Status Request and Response

The origin of EDI is known to everyone. The first industry was the transportation industry who wanted to use the EDI solutions as a technical advancement of their legacy systems. Also, the first-ever EDI transaction standards were dictated by TDCC (Transportation Data Coordinating Committee).

However, the TDCC standard does not exist as they were merged with the ansi x12 edi, which has now become the most widely used standard. 

For the automated services, such as the EDI in healthcare industry, new and practical strategies were aligned by WEDI. HIPAA was established as a safe passage to follow and implement a standardized format for electronic health care transactions. Today, these standards are integrated worldwide, that are meant to improve the efficiency and effectiveness of the health care system. Here is the list of transaction sets by the HIPAA EDI described below.

Distinct Healthcare Claims 

EDI Health Care Claim Transaction Set (837)

This standard was introduced for submitting healthcare claims billing-related information. Areas, where the claims can be sent are -

  • Provider to payers through clear housing or intermediary billers.
  • Transmit health care claims and billing information with different payment responsibilities.
  • Coordination of benefits and monitoring of billings of payment of health care services.

EDI Health Care Claim Payment/Advice Transaction Set (835)

This standard was publicize to do a lot of tasks, such as -

  • Make payments
  • Send remittance advice to EOB
  • Or both

through either a health insurer or a financial institution.

EDI Benefit Enrollment and Maintenance Transaction set (834)

The standard is meant for the employers, unions, insurance associates, government agencies to enroll members as a payer. The healthcare organization pays for the claims as well as administers the benefit or product or insurance contracted.

Also Read: Top Differences Between ANSI X12 and UN/EDIFACT: A Complete Rundown

EDI Payroll Deducted and Other Group Premium Payment for Insurance Products (820)

This standard was released allowing the candidates to make a premium payment for insurance-related products, such as request to make payment to the payee.

EDI Health Care Eligibility/Benefit Inquiry (270)

The standard was to understand the true eligibility to get associated with a dependent or inquire about the insurance requisites.

EDI Health Care Eligibility/Benefit Response (271)

Under this standard, the provider is required to respond to a certain inquiry or request of eligibility about the dependent insurance.

EDI Health Care Service Review Information (278)

This transaction set was declared to use the information relevant to health care for reviewing the outcome of the health care service reviews. For instance, the patient or the subscriber's info, such as its treatment, undergo review for certification or reporting purposes in review processes.

EDI Health Care Claim Status Request Transaction Set (276)

This standard helps the authorized agent or healthcare service provider or edi outsourcing providers to request the health claim status of its recipient.

EDI Health Care Claim Status Notification (277)

Here, the standard is used by the healthcare agents to dictate and notify the status of their health care claim. This transaction set does not replace the 835 transactions set as it does not support the account payment posting, which makes it different from the 835 claim format.

Why Is It Important To Understand These Format of EDI 

Because to pick the right EDI service provider, you must be aware of the EDI formats to evaluate the requisite support you need from your associate. 

These formats will aid you to decide the competent business model and further evaluate the services offered and methods used by the provider. 

To get things right, you also need to evaluate your resource's compatibility to get EDI integrated. They must easily comply with the requisite EDI file formats or must be able to easily undergo adjustments when necessary. 

How Outsourcing Helps?

In-House EDI Professional

Outsourcing EDI Service Provider

In-house EDI Hardware setup is expensive & require continuous monitoring & management

A third-party service provider is fast, efficient, & experienced

Require Onboarding, Infrastructure development, scalability Handling

Only scale when the business scales by providing customized EDI solutions

In-house EDI Integration require translation software to decode the data into readable text

Deliver reliable and updated infrastructure to meet business needs

In-house EDI follows the legacy format, hence lack the requisite learning curve

Offer advance features, such as cloud translation management 

Require regular staffing changes or training through skilled consultants

Vigilant and always ready to service, despite location & time differences


Also Read : In house VS Managed EDI Services: Which One is Right for Your Business?

How An Outsourced EDI Service Provider Assists for 276/277 Transactions?

As aforementioned, the 276 Healthcare claim status inquiry transaction set is used for requesting the status of the claim. The elements used for the request require -

  • Patient's identifier
  • Dates of Services
  • Provider Number 
  • Charges 

The EDI 277 format is the response demanded against the 276 requests raised. Hence, it can be gathered from -

1. Issuing a 277 in response to 276 requests.

2. Requesting for additional information about the submitted claim, without the need for 276.

Here the STC segment becomes the key element, used by the third party to provide the status notification. This segment encompasses the Claim Status categories, which are status codes and monetary amounts, which the service provider fulfills. The codes and categories that are filled denotes -

F- Finalized, which means competition of adjudicated processes. However, in this process you might not receive 100% success as a few codes can be rejected or denied.

P - Pending, which denotes the codes are undergoing process or review of payment claimed by the provider.

Healthcare claim transactions are usually technical that cannot be understood easily. With the help of a professional EDI service provider, you can file the right claim and get a relevant response in return. Let's take a scenario for instance:

In order to get the response to 276 claims,

  • The service provider first needs to submit the 835 claims and as an acknowledgment received 999*.
  • Next, your provider requests for the claim by issuing 276.
  • Which is the response by the payer by issuing the 277 status response.

Note: 999* denotes that the file claimed has been received successfully.

Similarly, to receive the additional information of the claim, the provider has to - 

  • Submit the same EDI 837 claims and receive 999 acknowledgments.
  • Later, the payer issues the unsolicited claim status notification to the service provider instead of the 276 claims.
  • Again the payer has to issue the request in order to retrieve additional information.

This is how 276/277 can interact with other transaction sets. But, only with the help of a professional IT services provider with EDI expertise, you can obtain the same results.

These uses of 277 Claims are determined from GS-08, ST-03, or BHT-06. The BHT-06 contains the following code that your outsource associate understands and values.

  • DG - Response (for request and response)
  • NO - Notice (for pending status)
  • RQ - Request (for additional information request)
  • TH - Receipt (for claim acknowledgment)

Benefits of Adopting Third-Party Assistance 

Associating with third-party EDI service provider with intense knowledge of healthcare IT solutions & services, you can benefit with -

Improved Data Quality - An EDI associate can reduce or completely remove the mundane and tedious manual data entry processes. An automated system can assist your finance department to predict things, such as profits, losses, & expected revenue.

Improved Timelines - When you have less error caused due to manual processes, you get enhanced & quick real-time processing. The reduced time to send, receive, and enter orders manually can be used for other strategic work.

Enhanced Efficiency - Outsourcing your EDI can release your employees from manual data entry and similar time-consuming tasks. The automated and upgraded EDI integration services can quicken the invoice and purchase order processes. 

Improved Turnarounds - Always stay updated and at the edge to compete with the market trends. Outsourcing EDI can uplift you by staying on top of your stock level thereby improving the overall business cycle. 

Reduced PaperWork - The most essential benefit, which is always spoken of, is the reduction of manual entries. EDI minimizes the need for paperwork, such as storing, mailing, printing, posting, and recycling. This advancement from paper to paperless also encourages a safer and greener environment. 

In a Nutshell -

To get started with the EDI solutions, you must outreach a reliable and skilled IT consultation services provider to guide you with the right outsourcing needs. They can evaluate the integrated management system in your business (Hospital). 

Integrating a HIS (Hospital Information System) with EDI enables you to automate the processes while generating the inquiry. An outsource EDI service associate can render the best fit format that complies with HIPAA standards for authenticated and secure solutions. 

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