healthcare edi software Caliber Health

Splitting 835 Healthcare Claim Payment

What Is Splitting 835 Healthcare Claim Payment The Electronic Data Interchange (EDI) consists of a file in a specific format that represents data exchanged in a transaction from a supply chain to EDI Healthcare transactions. 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, …

SNIP 5 HIPAA External Code Set Testing

The healthcare EDI specification allows for the inclusion of code values that may be pertinent to the transaction set, such as a claim or encounter. These code values can represent a data point as widespread as a postal or zip code, or as complex as diagnosis and procedure codes. The Workgroup for Electronic Data Interchange (WEDI) describes seven types of validation, …

A HIX 820 Overview

When the Health Insurance Exchange (HIX) network went online in late 2013, the healthcare insurance industry was challenged. They were tasked with reconciling new benefit subscribers to their related insurance premium payments and subsidies. Having the right EDI Software came in handy as health plans painstakingly assembled Excel eligibility extracts. They looked to invoice their Federally Facilitated Marketplace  (FFM) or State-based Exchange (SBE) …

EDI Onboarding Process: Trading Partner Setup

The Electronic Data Interchange (EDI) process for onboarding new trading partners to exchange Healthcare EDI files can be performed using files conforming to ANSI X12 specifications. This can be done manually with our FREE EDI Editor download or automatically using an EDI Gateway software solution. These Claim, Payment, and Remittance Advice files may originate from payers, providers, clearinghouses, or third party …

Tracking and Fixing EDI Encounters

There are several ways to intake EDI files, parse EDI data , and route EDI Healthcare transactions. However, there are often deficiencies that become quickly apparent as the level of EDI data visibility increases. Seeing into the EDI processing status of the in-flight data files is key to fixing EDI transaction errors. One useful tool is our or FREE EDI Editor -X12 …

TriZetto QNXT – Preprocessing Limitations

TriZetto QNXT is a longstanding leader in EDI healthcare administration platforms, supporting many lines of business including Medicare and Medicaid.  An important function of QNXT is its strength in claim pricing, member administration and billing management.  However, the provided QNXT toolset lacks flexibility in adapting to new processing requirements.  For example, it would be difficult to perform member lookup and …

healthcare edi software Caliber Health

Extracting Invalid Records in X12 EDI

The organization of the EDI information can be challenging, especially before establishing a streamlined process for EDI files. Often we find that EDI healthcare transactions can be easily managed in EDI Software systems that have a healthcare focus. There may be countless methods or trade secrets that each system utilizes to achieve that goal. However, there are some patterns or …

TriZetto QNXT – EDI Reporting and Tracking

Each day health plan administrators look forward to the challenge of loading EDI 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 the plan’s EDI Software workflow. Drilling into the steps along the inbounding process, challenges emerge which can present insurmountable obstacles …

healthcare edi software Caliber Health

APCD Claims Database Submission Guidelines

APCD implementation by state remains variable and dynamic. Massachusetts maintains a comprehensive All-Payer Claims Databases (APCD) 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 ACPD feasibility study which determined …

CAQH CORE Certification Tips

CAQH CORE certification demonstrates that health plans, clearinghouses and software vendors meet federally mandated operating rules when exchanging HIPAA EDI transactions. Internally for organizations, the certification process provides value by exercising a broad variety of test cases. Last but not least, CORE specifies the message envelope details for exchanging EDI over two types of HTTP endpoints, reducing the implementation times that custom message formats …