Aug 10, 2021 Admin

EDI Service Provider

Frequently Asked Questions for Benefiting from Outsourcing EDI 834

The Healthcare industry manages voluminous data every day. The data is not that only of a patient, but also the insurance providers and payers. Managing variable data is a challenging task, which requires a robust and modern system. EDI solutions are known to best fit for focusing and remediating these challenges. However, integrating EDI requires expertise and architecture that complies with the modernized solution. 

If you lack the requisite skills, you can simply outsource your integration services to an experienced EDI managed services provider. They can evaluate the best solution that streamlines your process as well as provides a seamless integration solution that aligns with business objectives.

But, before you jump into hiring a service provider for EDI outsourcing, you must investigate their knowledge.

What to Look For in Your EDI Service Provider?

The EDI provider that you want to collaborate with should be responsive and customer-focused. In order to judge that, you observe the personalized approach to serve you, the agility with which they address your questions and concerns. 

Despite the products and services offered by the EDI provider, the solution offered to you must be able to comply with the business needs. Hence, the EDI solutions offered must be highly expandable, always available, and remain consistent.

Relevant experience is essential for your EDI provider to deliver efficiency to your company's needs. Partnering with a reliable and experienced service provider ensures that you get the best advice, tangible solutions, and real value to your operations.

The solution offered to you must be friendly and intuitive yet powerful, requiring little to no training for integrating or pairing with other important systems, such as ERP systems. So, if you are looking for a perfect solution provider, check out the relevant questions you can ask them. 

Quick List of Question That Can Be Asked

What is EDI for Healthcare?

Healthcare is integrated with the HIPAA rules, essential for any healthcare provider or healthcare clearinghouse to transmit claims and other information related to a patient in a specific X12 EDI transaction. 

So, is Healthcare EDI Different from HIPAA EDI?

Healthcare is a sector that can leverage the EDI technology system,  whereas HIPAA is the ACT that EDI service providers abide by. HIPAA stands for Health Insurance Portability and Accountability Act, leveraging healthcare providers for HIPAA Ansi X12 EDI transaction sets for claims submission, enrollment/disenrollment, eligibility, payment to the provider, claim status, certification/authorization, and premium payment, healthcare insurance plan.

How do Transactions take Place in EDI Healthcare?

A single business document is termed a message in human language and transaction set in a computerized language. There are distinct EDI transaction sets for different functionality, such as EDI 834 for benefit enrollment & maintenance, which lets employers communicate employees' health insurance and enrollment & maintenance data to insurance carriers.

How do Service Providers Define EDI X12 files Validation?

Since EDI is a computerized method of message or information transaction, thus may have problems such as invalidated message contents. So, an EDI managed services provider ensures that your EDI systems include SNIP Types or SNIP Levels to check whether the given EDI message is meeting the specified criteria. Additionally, experienced personnel can offer validation processors to provide a preliminary overall format check.

How to ingest X12 files and export them to a flat-file?

Any EDI service provider offering comprehensive solutions is well aware of the need for transforming the files in an XML format and human-readable format. The EDI messages are parsed, with the help of an EDI translator, into a common format to further convert into a flat file to send. Care providers also support and offer EDI ingestion methods, such as AS2, (S)FTP, and local files to make conversions seamless. 

How does the EDI parsing process take place?

EDI parsing is meant to match the incoming data with the defined schema to identify and fix or flag the issues appearing during data transformation. These errors can appear in different forms, such as data type mismatches, invalid records, incorrect values, incorrect element usages or segmentation, & much more. 

Does Data Mapping involve Data Parsing? 

No, they are entirely different. Mapping is the method to convert the information into unique formats - company-specific format or standardized industry-wide EDI format. The format enables the care provider to transmit the data to the trading partner easily. A robust EDI mapping software is requisite with the capability to map source data fields to targeted data fields converting to different formats such as XML, Excel, JSON, databases, or other EDI formats.

Also Read: Mastering EDI Mapping: A Step-by-Step Guide

Is there any software required to convert XML to EDI and EDI to XML?

Usually, Data Mapper is used for converting XML to EDI or vice-versa. Data Mapper is a graphical editor that generates XSLT transformations that are responsible for changing data to different formats. You can partner with a care provider to offer extensive support to your software for uninterrupted graphical functioning throughout.

People strongly comment about EDI being an old technology! Should I still consider it?

Instead of using the term 'old', you should call EDI 'mature'. Yes, EDI has been there for a very long time and has evolved continuously to make transactions seamless and secure. EDI has embraced new technologies and tools to stay competitive in the market as well as making communications efficient between companies, especially the healthcare industry. EDI is so entrenched that we will continue to see it more in the upcoming years!

Should I consider outsourcing EDI or should I hire an analyst?

Outsourcing will be a better choice to consider than hiring an in house EDI service provider, especially when you are in a growing period. Outsourcing your EDI requirements is handing over your requirement fulfillment responsibility to managed providers. They will provide you with the end-to-end EDI solution, such as developing maps to linking documents to recruiting partners, so that you only focus on your core business processes. Additionally, you do not have a lifetime commitment, saving you from spending every month on a resource. 

What are EDI-related industry associations and data standards, and what are their relevance?

Industry associations are essential as they will leverage you to follow the best-used industry practices by competitors in terms of EDI usage. Associations work parallel to build new standards to exchange documents for streamlined and secure processes. 

What types of EDI transactions can we receive on a single file for a single member?

Integrating EDI for specific transactions set, such as 834, will produce a single 834 per member every day. Care providers can add, term, change and cancel the transactions using exceptions. These exceptions help companies to produce more than 834 transaction reports for editing or analyzing the action plans. 

Also Read: Know Different Types of EDI Services and Which One Suits Your Business Better?

How do we handle 834 transactions received from the managed provider where we would be unable to send a 999 acknowledgment?

Irrespective of your industry or managed service provider hired, all transactions are followed as per standard EDI process flow. Here, when you are unable to process the 834 due to failed syntactical analysis, you can send an Interchange Acknowledgement (TA1) as a response to your trading partner. Even if the trading partner is unable to produce TA1, you can raise your concern to the support team. However, ASC X12's website has a complete scope of TA1 with its uses for the EDI users to perform.

Will the first file after go-live be an audit file?

The audit or the verification file will be an 834 file containing Maintenance type Code for either audit or comparison with a Loop ID to offer real-time visibility to the current enrollment plans. You can request complete verification along with the initial audit file.

While the process is transitioned to the 834 formats, do the clients get a new CIN number?

No, the client can continue to perform transactions with their current CIN Number easily.

Is there a list of all possible multiple transaction scenarios and their usage?

Is there a list of multiple transaction scenarios with their usage? Does the TERM transaction followed by an ADD transaction signify a break/gap in coverage?

In order to send multiple transactions to the same member, you can look into these two scenarios -

Scenario - 1

Taking a scenario, where a member has coverage for a year, starting from 23/2/2020 to 24/2/2021. Let's say there is some change in the information of the member, hence to communicate changes, you will have to send an ADD transaction followed by TERM transactions extensions. 

Another Scenario - 

In this scenario, we may see the type of transactions created when there is a gap of a month or so between the two coverages of the same member. 

Let's say the coverage plans range from 31/1/2020 - 1/2/2020 and 1/3/2020 - 2/3/2021. Here the month of February 2020 is left without coverage.

In order to remove the gap, the trading partner may send the second coverage period plan to the EDI professional services provider, who further will try to fill in the gap through different scenarios, such as -

#1 The coverage details can be sent on 4/2/2020 for which the transaction created will  be-

Starting and ending the TERM transaction from  31/1/2020 - 1/2/2020.

Next, ADD transaction with coverage 2/3/2021.

#2 The coverage details can be sent after 25/1/2020 (TERM Process) for which the transaction will be created as -

ADD & TERM transactions with coverage starting and ending from 31/1/2020 - 1/2/2020.

Next, ADD transaction with the coverage date 2/3/2021.

# 3 Sending the coverage for coverage after 1/2/2020 (TERM Process), then the transaction that takes place will be -

An ADD transaction that starts from 2/3/2021.

#4 When the insurer identifies the gap covered, the transaction can be sent to the managed provider to tell about the continuous coverage that is 31/1/2020 - 2/3/2021 in the EDI systems. The transactions created will be -

A CANCEL transaction from the date 1/3/2020.

Then next, ADD transaction for the coverage date 31/1/2020.

What is Renewal Date? Is it the last day of coverage?

Renewal Date can be referred to as Recertification date. Yes, this date can also be defined as the last day of the coverage, but the last day is of the previous month. This means you have a month left before the eligibility ends. 

If a member changes the case number, where to find the effective and changed date, and what happens if the change occurs mid-month?

Yes, there are chances when your members can change the case number. The change of the case number in EDI 834 undergoes a CHANGE transaction that becomes effective from the very next month on the 1st after requesting for it. 

Additionally, the change of the effective date can be determined by using the 'Maintenance Effective Date' segment with the qualifier 303. 

How are plans notified for member disenrollment? Are the TERM transactions for most disenrollment’s included on the file received on the 26th of the month?

In order to receive the notification regarding member disenrollment as a part of the terminator process, you can refer to the MEC 834 companion guide. The transactions - Termination End Date and Termination Process Exceptions are under HIPAA transaction instructions.

This transaction has nothing to do with the establishment process, as the members can continue to process and plan on following the end data guidance in the model contract. 

Can you provide more information on what the Other Payer Policy Sequence Number is, and will it always be 16 digits?

The Medicaid or Medicare are given beneficiary ID, which is an 11 digits MBI number. The other payer policy sequence number contains a 16 digits ID that also indicates the third party commercial coverage. 

When Spend Down/Excess Income gets updated, does the file then include an effective date of change?

Again, the change appears in the Managed Care Enrollment 834 under the guidance of HIPAA compliance. The spend-down/excess income will be shown in the file after updating it.

What is the method to handle potential day-to-day changes to the elements involved in rate code calculation (age, sex, Aid Code, HIV status, transgender status, homeless status) and the downstream effect involving premium billing, claims payment, and vendor services received in everyday 834 files?

The changes or the updates made in everyday transactions related to the eligibility category resulting in the Rate Code or RRE change triggers the EDI 834. 

Will unborns and newborns be issued a default rate code?

Only when a newborn's date and gender information is updated in the EDI systems will only the rate code of information be sent. The unborns and even newborns without requisite information will not be issued a rate code, thereby not valuing the rate code field.

What happens when the Roster file data definition differs from the data in the 834 files. Should we expect the Roster-specific definition to carry over to the new 834, or will it confirm the 834 specifications?

There is no need for managing different sets of codes despite differentiation in the file data definition and 834 files. Everything written or added to the codified list in the X12 transactions needs to be coded in the X12 specifications. The real advantage you get here is, improved data accuracy, quality, thereby eliminating the need for maintaining different data sets of code for the same element.

Can we expect home nursing members on MCE 834, and what details can we observe?

The appropriate RRE or rate code allows you to check the nursing home members on 834. Companies using the Healthcare EDI software solutions will have to continue to use plans to utilize RRE reports. Additionally, utilizing the plans will provide you with the start and end dates of the RRE codes along with the current nursing home providers' IDs.

In a Nutshell -

Associating with a managed service provider will eliminate the challenges with EDI 834 that you face. Outsourcing will liberate you from lifetime resource training or quipping a dedicated one for your EDI system. You can own the highest level of flexibility, control, process efficiency, minimal delays, and reduced error. Whether web-based or EDI service bureaus, connect with a proficient and dedicate EDI benefits provider to leverage every opportunity for data integration.

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