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 Studio Toolbox. Is a useful tool needed to respond to issues once they arise.

Choosing an EDI Gateway Solution

Putting on the hat of an analyst or operator tasked with ensuring that claims are successfully processed from intake to delivery, I may have a few key concerns with any system in the overall processing workflow.

  • Tracking the life-cycle of claims is difficult or requires many steps
  • Troubleshooting failed messages and determining root causes is time-consuming and requires both business and technical expertise to dig through complex systems.
  • Re-submission often requires reprocessing the entire file or manual edits to files in unfamiliar formats
  • Resolving these issues commonly results in hours or days of lost productivity.

Some of these concerns originate from the system chosen to handle the EDI files. Tracking EDI encounters may be difficult if EDI ingestion, EDI validation, EDI transformation, and EDI file routing is performed by custom in-house applications. As is often the case, custom systems that have evolved over many years of in-house development may not compare to a proven EDI Gateway that provides a clear understanding as to find EDI files failed validation and why .

If gateway operations are performed by an integration platform or other off-the-shelf solution, then specialized expertise may be needed to translate seemingly cryptic error messages and determine the root cause of an issue.  For example, as detailed in a recent blog on EDI Data Reporting and Tracking , an error may be presented as several related errors referencing different files in XML format. However, without experience and knowledge in how EDI files are translated into XML, the task of determining the root cause and fixing it can be quite overwhelming.

EDI Gateway: Encounter Management Process

With a healthcare specialized EDI Software , viewing the status of your encounters, enrollments and other EDI files is simple and approachable. For example, below is a screenshot showing the EDI Gateway sample of encounters and their statuses.

Within the Messages page of the EDI Gateway , there are several things that can be accomplished:

  • Drilling down to a narrower set of files by utilizing the date filters.
  • Including a filter on any element within the file, such as an ID, name, or control number. The list of element names is also configurable and can include any element contained within any EDI file.

Aside from the clarity in the files that have succeeded and those that have failed, it is also just as simple a task to identify the issues within the files. The EDI Gateway screen capture below shows the ease in viewing status of every sub-process or step that the file went through from its initial intake to its ultimate completion. Some of these steps include:

  1. Intake of the file, a HIPAA 005010 837 Professional file with 10 encounters.
  2. Validating EDI files using WEDI SNIP rules.
  3. EDI Validation resulted in splitting EDI file to extract and hold the 1 invalid EDI encounter for later processing.
  4. By leveraging, the portal below shows, 9 valid EDI encounters were retained in another file that ultimately continued on using relational databases in healthcare . Our recent blog goes into more detail on using T-Connect to ingest EDI data into databases .

It is important to note that we can see the EDI validation error encountered in the file by selecting the EDI validation step showing the 1 in the Error Count column. This clearly shows that there was a single EDI validation failure (SNIP 2) encountered where the PER communication number segment contained an invalid PER03 element of ‘AAA’. This level of clarity is only obtainable with an high quality EDI Gateway .

The natural next step after identifying that an error has occurred, is to determine what can be done to remedy it, and hopefully remedy the issue without jumping through many hurdles. Thankfully, resolving the EDI validation errors is just as easy as identifying the error.

Resolving EDI Validation Errors

As can be seen in the EDI Gateway screen capture below, clicking on the ‘view message’ icon opens up the currently selected file in our  EDI editor tool . X12 Studio presents the EDI file in it’s natural hierarchical structure, along with all EDI validation errors, and lists values for fields that require certain values selected. Generating 999 Acknowledgements and generating CMS 1500 Form from EDI data are some of the other capabilities provided by this X12 Studio Toolbox.The EDI file validation error message shown in the X12 Studio Toolbox matches the error message shown in the T-Connect EDI Gateway portal previously. Clicking on the error in the EDI ‘Validation Results’ tab highlights the PER error in the file. Selecting the PER03 element shows the 3 possible values for PER03 [EM, TE, and FX]. Now we know that the PER segment is a communication number, and the PER03 element represents the qualifier associated with the PER04 value a phone number in this case. Thus, selecting ‘TE’ from the list immediately re-validates the file and clears the error displayed.

Next up is resubmitting the now fixed edi encounter into the system for re-processing, also shown in the portal screen capture above. Re-processing, after being queued up, can be done either immediately, or as a scheduled batch for all resubmitted files. Below, we can see that after re-submission, the now corrected encounter was re-validated successfully, the EDI platform persisted EDI 837 files to Databases .

Conclusion

As shown above, some of the common issues in tracking, fixing and resolving common claim, encounter and enrollment processing issues is painless with the proper EDI Gateway . Powerful and complete EDI parser and X12 validation, alongside EDI encounter tracking and reporting to lower the day-to-day overhead inherent in managing complex healthcare EDI workflows.

 Caliber Health is an EDI Software Company  dedicated to making EDI easy for people and computers.

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