Knowing how to efficiently validate ASC X12N – Insurance transactions with Electronic Data Interchange Software or (EDI Software) is a major contributor to the effectiveness of 5010 payment and claims processing organizations. It’s critical that health care organizations quickly and accurately identify and respond to invalid EDI 837 claims, EDI 834 enrollments, or EDI 835 payments. Many healthcare benefits processing organizations appoint an entire business units as stewards of the tens of thousands of transactions that are transmitted between healthcare benefits payers, providers, and third party administrators, providing auxiliary services. These business units are often hard-pressed to scale and manage the quantity of EDI X12 validation error detection when processing EDI claims, enrollments, and payments within the limitation of their current EDI tools.
Choosing the Right EDI Validation Tools
Caliber Health’s healthcare EDI Software Comparison is a great place to zero in on the best EDI software for an organization healthcare data processing challenges. There you’ll find EDI software solutions for actionable insights, alerting, and painlessly responding to invalid X12 EDI transactions flowing in and out of an organization.
The T-Connect EDI Gateway solution consists of several components working in unison to introduce, augment, or replace a legacy EDI processing system.
· EDI Gateway Portal, advanced reporting and X12 data management platform to track EDI data, make file corrections, or set up custom data processing routes or workflows for EDI transactions.
· EDI Gateway Database, fully relational SQL Server databases custom developed as the fastest method to store the full spectrum of HIPAA transactions.
· EDI Gateway APIs, stored procedures to simplify the manipulation of HIPAA transaction file data. Including the ability to parse EDI files into .Net objects and persists them to SQL Server databases.
· EDI Gateway X12 Validation Editor, simplifies the development process with features like: editing, EDI validation, and EDI test file generationfor sample EDI files of any healthcare EDI transaction type.To demonstrate this remediation and re-submission scenario we will save an X12 EDI file with ten 837P files (professional claims) to the EDI software intake folder, one of the many ways to consume and process an EDI transaction within T-Connect. This file contains nine valid claims and a single invalid claim. The goal of the intake is to parse and persist the file into our T-Connect EDI 837P Professional database, however as will be shown in the proceeding sections, the invalid claim will have to be fixed before it can succeed.
The below screenshot shows the home page of the site, showing all X12 EDI transaction set types currently authorized for viewing by the logged in user, in this case Administrator. This page also shows the date of last activity for a HIPAA transaction set, as well as total number of successful and failed transactions.
EDI files to X12 Database: How to Parse and Persist Claim Data
Clicking on a row, such as 837P Claim, brings us to the next page, one level deeper in navigation to the Messages page, showing a history of processed files (transactions). We could use this EDI Software to search, sort or filter to a specific transaction, however, we can see that there was a single error out of the 10 total rows in the first entry in the rest list.
Selecting the first row from the results, we are brought to the next page (Details) showing the resulting processing history of the transaction selected. This history is represented as steps within an EDI workflow route. These steps below provide a sample route performing SNIP Level Validation EDI X12 file validation, acknowledgment generation, and routing of the valid and invalid records of the transaction. The route is user configurable within the portal.
Splitting EDI 837 Claims
In the below page, we can see an EDI 837P file validation error produced by the first step, SNIP Level EDI X12 file Validation, identifying one of the ten total EDI 837P healthcare claims has an EDI file validation error. In subsequent steps, we can see the EDI Software highlights that nine valid records split out of the claim, and the single invalid record isolated within its own transaction message. The act of splitting the invalid records out of the transaction to allow the valid records to succeed is one way of processing the EDI. Another option available within T-Connect is the complete suspension of the entire transaction, in this case all ten claims would have been prevented from completing the workflow. For our purposes, we have configured the workflow route to allow partial loading of transactions, the nine valid claims in this case.
We are able to view the actual EDI X12 file Validation failure present within the message at the bottom of the Details page. Here we can see that the PER segment had an invalid qualifier ‘AAA’, a SNIP Type 2 HIPAA Implementation Guide Requirement Testing error, due to the qualifier not matching an expected value.
The next logical action may be to correct the now isolated invalid record for reprocessing. Correction is easily done by clicking on the X12 Studio icon to the right of the step with the invalid record, launching the T-Connect EDI Gateway featured EDI X12 file validation tool (free trial download), X12 Studio Toolkit Pro, we have several capabilities around validating EDI Claims and working with of HIPAA 5010 EDI X12 transactions. Claims file validation is done when launched, showing 837P validation results in the bottom console and EDI X12 file validation results panes.
We can navigate through the free EDI file validation tool by expanding the EDI file tree nodes in the main section.
Locating EDI X12 Validation Errors in EDI 837P Claim Files
However, finding the invalid line is quite easy, done by clicking on the first row in the EDI X12 validation result pane. This switches the focus to the line containing the error. From this, we can see the error highlighted in segment PER, element 3 (PER03), value ‘AAA’. Not only do we clearly see the highlighted EDI X12 validation error, but reviewing the properties pane on the right we can see a wealth of metadata including min and max occurrences, EDI file validation rules, enumeration of expected values. The latter is important for our scenario, as opening the drop down list for PER03 , the X12 Studio EDI tool suggests possible values expected for the qualifier, EM, TE, and PH.
In our scenario, the correct value for PER03, as a qualifier of PER04 is ‘TE’ for PER04’s telephone number. Selecting ‘TE’ from the list in PER03, the entire transaction is immediately re-validated resulting in the removal of the previous EDI X12 validation failure message.
Now that the file is valid, re-submission can commence by clicking on the ‘Resubmit’ button on the toolbar. This allows for the re-submission of the now valid file back into the T-Connect EDI Gateway Software services, where it is sent through the workflow route shown previously. The single corrected transaction is then re-validated, and can be seen in the portal as such.
We resubmitted the previously invalid X12 EDI file, also removing the previous EDI X12 validation failure message from the EDI Gateway portal, though all message history and failures are retained in T-Connect for later viewing.
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