Overcoming EDI 834 Challenges by Outsourcing EDI Solutions

There has been steady adoption of EDI in distinct industries, which has given a huge opportunity to the EDI outsourcing services. The 834 standard of EDI for healthcare benefits enrollment and maintenance is an extensive and imperative service that the healthcare industry may cover. Reliable third-party insurance companies offer these services, however, to integrate them requires expertise to ensure smooth flow of information while processing health plans.

Here we will understand the challenges that a healthcare industry faces while transmitting their data into EDI and how an outsourcing EDI service provider can overcome these challenges seamlessly. But, first let’s understand the meaning of EDI 834 standards and why it is important!

834 EDI Transaction Need and Importance

The electronic data exchange 834 format is a transaction code used to transmit or enroll manual data sets, such as members and employees data, into the ANSI X12 EDI transaction set, which is a healthcare benefit plan.

The EDI 834 healthcare program is specified by the HIPAA 5010 standards for electronic enrollment, which further assists in benefit plans and subscriptions.

The format of EDI 834 begins from filling in reference identification, transaction purpose code, & mentioning the date/time & action. The format demands the policy number, sponsored by, personal details, insured benefits, organization & more.

The EDI format is a standard format that establishes the data for basic enrollment into a content format that is abiding by all contexts of electronic data interchange.

Further, the 834 healthcare EDI is equipped with maintenance services, such as easy modifications, additions, and deletions of the existing enrollment.

The information about employees or members of an organization is submitted to the responsible health insurance claims and administering service provider. The 834 document consists of –

  • Subscriber’s name and identification
  • Subscriber’s eligibility and benefits information
  • Service identification
  • Planning on identifying network

The transaction of 834 is linked to 999 Implementation Acknowledgment that confirms the file retrieval and feedback on document acceptance.

However, EDI 834 consists of vital & critical information that needs to be handled carefully. It also comes with some pitfalls that need to be underlined to ensure a smooth transaction.

Challenges with Processing EDI 834 Files

Manual Intervention

Sometimes manual interventions are needed when the systems are unable to handle high-level volumized EDI transactions, the IT professional service employees have to manually handle the labor-intensive, which increases the manual effort.

Large Monthly Files

Here again the voluminous each month’s transaction files cannot be processed without manual intervention. Hence, you may find companies struggling with complicated parsing methods to process EDI software solutions.

Transaction Types and Its Order

There are different types of source systems that make up an EDI 834. Companies face issues related to files that go out of order. Common cases such as terminating a file of a person before adding the member to the plan can increase the complexity unknowingly as well as induce inaccuracy of membership records.

Corrupted Files

Companies must keep track of their invalid formatted files or corrupted files. They must be rejected before intaking them for any process. Keeping track of such files ensures accurate information in and out.

Member Matching Logic

Member matching logic aids in finding EDI 834 files with names and NM1 values. Some files may not have an exact match system of record hence it may take a bit longer than usual time to find the files. Herein companies may look up to complex algorithms to find their match.

Understanding of the Receiver

This is a common challenge faced by companies using EDI as a service without complete knowledge. You may have sent a comprehensive EDI 834 membership file, the software perceiving the file can differ from your understanding that can cause serious clashes.

EDI 834 Custom Rules

Every company using an EDI 834 format may have distinct rules to ensure data validation as per their understanding. However, there are a few companies that treat EDI 843 as a ‘black box’ which acts as a roadblock to enable the custom rules and enrollment policies making the file loading a risky process.

Variation of EDI 834 Standards

You need to understand that following an X12 5010 834 ANSI standard is vital for seamless and secure transactions. The problem comes when you are associated with a third party that does not follow the protocols thereby increasing the complexity of processing EDI files and time to fix them.

Subscribers Versus Dependents

Just like the out-of-order transaction type, the subscriber’s records could go out of order, which directly impacts the accuracy of the EDI processes. This challenge may lead to the loss of some of the most essential information, such as adding a family member to the subscriber’s group.

With continuous accelerating data in the healthcare industry, where organizations have to keep a record of their employees as well as their patients, it becomes essential to have a dedicated platform to manage data and a dedicated team to manage the platform.

Hence having an association with the right skill requires utmost research. Also, you need to understand when it is right to outsource your EDI services.

When and Why Do You Need EDI Outsourcing Services?

Understanding your key business requirements and resources, underlining finances and personnel, you can look out for an outsourced or hosted EDI solutions provider.

Outsourcing your technical as well as complex EDI responsibilities can accommodate your EC needs at comparatively cost-effective prices. Compared to an in-house EDI service provider, a  hosting or outsourcing EDI services assist you in achieving technology-relevant benefits without the overhead stress of giving up your ownership.

Any hosted EDI or web-based EDI service provider offers a robust online format for the companies looking for healthcare software solutions.

Companies can leverage the versatility and availability of the high transaction volume with minimum to no performance issues.

Benefits of Outsourcing EDI Solutions

  • You are always updated and your system is imbibed with the latest technology as any product engineering services provider assures you to offer the upgraded facilities and features.
  • With the help of a reliable and vigilant service provider, companies can quickly enter and scale in new markets and territories.
  • Being connected with an external service provider for your complete EDI deployment to value-added services, you can market your services globally.
  • Companies can leverage the expertise of an EDI solution provider that assists you in enhancing productivity, delivering a new level of information to the supply chain and business partners.

Factors that can lead to Need for Outsourcing

Strategic Need – When the enterprise wants effective and sensible personnel to manage the supply chain management system while letting the employees work on other strategic work.

Effective Management – When an enterprise needs a professionally managed EDI service provider to manage comprehensive services ranging from supply chain to cash cycle in the healthcare industry. An efficient TPA can manage several relatable activities without allowing you to spend much for an entire team for each functionality.

Business Complexity Handling – An outsourced EDI service provider can swiftly facilitate the most tedious tasks of all levels. They will also ensure utmost and multi-layered protection against any vendor’s chargebacks, scoreboard penalties, or other negative consequences that can delay transactions.

Urgency In Project – One of the most acknowledged factors for outsourcing EDI is the urgent demand of the project that requires the best EDI solution. When your in-house service provider is incapable of delivering the requisite solution, you need a hosted solution.

Managing Trading Partners – When you have competitive and productive trading partners aligned at your doorstep, you need the right mind and compatible personnel to guide you to manage them. A helping hand as a hosted solution provider not just makes management easy but also improves your customer service.

Integrating Customization – Another beneficial aspect that would encourage you to outsource is the leverage to customize. Companies can always look into the type of EDI solution they want as per company requirements and with the assistance of a dedicated software development team for your perfect software solution.

Fundamental Question That Should Be Asked

The Healthcare industry deals with a lot of challenges each day, hence requiring a robust as well as flexible solution and solutions partner. They need to evaluate whether the outsourcing EDI service provider delivers expertise in both traditional as well as modern infrastructure management that is patient-centric.

Additionally, it must be noted that the associate is updated with clinical & financial information required to manage far more than robust IT infrastructure.

The solutions provided must be integrated with predictive analytics, business intelligent enablement, new models of reimbursement, clinical data exchange, decision-making concerning in-sourcing & outsourcing, and providing mobile & open application services. Hence, prepare a list of questions that can uncover their proficiency. But, before that check this list of questions to evaluate your requirements.

  • Name the key factors and metrics that define the need for outsourcing EDI partners. Do the factors include cost, retention of control, dependability, or any other?
  • Are there any strategic undertakings that require balancing the in-source and out-source?
  • If your business is flowing effectively what are the factors that encourage you to outsource? Is EDI operation vital for your business?
  • How do you define flexibility and dependability?
  • Is there any strategic differentiator in your business? If yes, then which ones?
  • Do you need to shift from easy-going traditional legacy services to augmented resources? How can the new methods improve the business?

To Conclude –

To meet everyday business challenges especially when companies need to prioritize strategies, allocate resources, and meet urgent needs while staying competitive in the market, companies need a reliable hosted IT consultation services provider, who can aid in evaluating the current needs with the right solution.

EDI solutions encompass core administrative services, such as eligibility, claims status, inquiry & much more but at the same time assist the companies to remain flexible and agile with their services.

Now is the time that you redefine your organizational operations and move ahead making the necessary revisions that can align with the changing market landscape.