EDI GatewayT-Connect EDI Gateway Platform Improves EDI workflows for healthplans and intermediaries
Track, Report, and Automate EDI Validation Processes
Gain enterprise-level EDI processing speeds and data visibility.
POWER YOUR HEALTHPLAN’S COMPETITIVE ADVANTAGE
Our EDI Gateway software product simplifies administration data processing with innovative EDI healthcare solutions. Access the data using our easy-to-use portal screens.
Reduce complex tasks with our innovative EDI software solutions that automate workloads from hours to minutes.
EDI GATEWAY FEATURES
SELECT EDI GATEWAY CLIENTS
SIMPLIFY HEALTHCARE DATA ADMINISTRATION
With data ownership, harness the power of innovation by reducing overhead costs associated with claim and enrollment processing. Easily view, edit, validate, and resubmit on-the-fly with our T-Connect EDI Gateway. Provide access to EDI outside of IT organizations with self-serving screens and dashboards. Meet legislative requirements and analyze key metrics to improve compliance and reduce encounter errors.
Claim and Encounter Reconciliation
Streamline 5010 payment and claims processing with Claim and Encounter Reconciliation Services. See improved processing speed and capacity while significantly reducing submission errors.
270/271 Realtime Benefits Eligibility
Streamline 5010 payment and claims processing with Claim and Encounter Reconciliation Services. See improved processing speed and capacity while significantly reducing submission errors. Learn More >>>
Gain insight into EDI 837I, 837P, 837D, 277CA, 999, 835 transaction processing. Access reports that quickly show which are claims are paid, rejected, and acknowledged.
Member Enrollment Management
Take member enrollment to the next level. Go far beyond the ability to parse and integrate 834 documents. Easily access, modify, track, and correlate enrollment data to simplify the administration process.
WATCH OUR EDI GATEWAY DEMO
What is an EDI Gateway?
An EDI Gateway solution for healthcare provides an integration backbone for connecting your trading partners with your core healthcare applications. It’s used by health plans, Third Party Administrators (TPAs), clearinghouses, and other healthcare software companies. An EDI Gateway solution can be owned, hosted, or managed service offering. For healthcare, the system provides security, HIPAA compliance, and all of the necessary components to process EDI administration data.
Components of a EDI Gateway
An EDI Gateway should provide connectors for file intake and delivery. EDI connectors typically used for healthcare EDI include SFTP, HTTPS, File, and Databases (internal). There are some key attributes that each connector should provide, an example of File connector uses the following configuration:
- Type – ‘File’
- Location parameters – ‘C:\EDI\in'
- Polling interval – ‘60’ seconds
- Credentials – (for secure connectors like SFTP)
- Custom naming – ‘[EDI file name & datetime stamp]’
- File filtering parameter – ‘*.*’ (all file extensions)·
Parsing and validating EDI is provided by EDI Gateway systems to process ANSI X12 file messages into a memory structure based on a pre-determined schema. From there, enrichments and rules are applied to the message payload. It’s important to parse EDI and validate EDI according to a HIPAA compliant schema. Typically that schema has a minimum validation that includes SNIP level edits 1, 2.
- Processing typically includes EDI parsing, Trading Partner resolution, EDI validation, 999 Acknowledgements
A trading partner is configured as the sender and receiver of EDI files. It typically includes an agreement between you and your partners. This agreement uses values from the EDI outer envelope included in the ISA/ISE and GS/GE segments. An EDI Gateway uses Trading Partner configuration when processing EDI files to resolve which agreement, mapping, and routing to apply.
An example of some of the values include:
- Transfer Mode – SFTP, HTTPS
- Inbound Envelopes – Enable Routing, TA1 Interchange ACK ISA 14
- Outbound Envelopes – Usage Indicator, Production versus Testo Transaction Sets
- File delimiters and identifiers
- Authorization type
It’s crucial to have a minimum of SNIP Level 1, 2 for HIPAA X12 EDI transactions. This ensures that the EDI file is structural and syntactically correct. Higher SNIP Level edits provide additional industry level rule sets.
Examples of Higher Level SNIP Edits:
- SNIP 3 – Claims Balancing
- SNIP 1, 2 – standard integrity, structural and syntax for implementation guide
- SNIP 3 – balancing tests
- SNIP 4 – segment situational tests
- SNIP 5 – external code set tests
- SNIP 6 – product type, type of service tests
- SNIP 7 – trading partner, specific tests
Typically, healthcare EDI companies require their own set of custom business rules in addition to SNIP edits. For example, rules for checking duplicate claims or fuzzy matching members when an EDI file is received.
Examples of custom EDI rules include:
- Duplicate 837 claim or 834 enrollment records
- Member lookup or fuzzy matching
- Already existso Custom enrichments
An EDI Gateway should provide mapping and transformation tools. Translating source EDI data files into the destination file format is a common development task.
- Enrich message
- Lookup values and transform
- Logic based on rules and transform
- Transform custom format to canonical or standard EDI format
Most EDI Gateway software solutions will provide a way to implement orchestrations as workflows. Typically, these orchestrations are integration flows in nature and are not business-based.
EDI orchestrations in healthcare may look something like the following:
- Connector to pick up EDI file
- EDI Parse, EDI Validate, Resolve EDI Trading Partner
- EDI file Transformations
- Route file to destination
- Connector to deliver an EDI file
Standard Formats Support
A EDI Gateway for healthcare companies, should provide support for all 5010 X12 EDI transaction sets.
- Claims – 837I, 837P, 837D
- Enrollments – 834
- Benefits Eligibility – 270/271
- Authorizations – 278
- Claims Status – 276/277
- Post Adjudication Claims – 298, 299, 300
- Remittance Advice – 835
- Acknowledgements – 999 (ACK)·
It’s common for an EDI Gateway system to support non-HIPAA file formats such as flat files and CSV files. Typically these are translated and transformed into EDI files somewhere at the edge of the integration process.
Examples may include:
- Flat Files, comma delimited
- Flat Files, positional
- CSV files
- XML files
- JSON EDI payloads
Real Time Transaction Support
Hosting a real time 270 / 271 eligibility service and API is critical to any EDI Gateway system in healthcare organizations (typically health plans). Real time service is typically CAQH CORE Phase II certified. It must meet CORE guidelines such as turnaround times, payload formats, and security.
Benefits of a certified real time 270 / 271 include:
- Lowers administrative efforts
- Lowers call center volume
- Provides quick turnaround for providers that are inquiring about eligibility and authorizations
It’s important to complete the EDI file acceptance process with an immediate acknowledgement. This 999 acknowledgement (ACK) provides details on what has been accepted and rejected.
- Accepted – IK5*A~ / AK9*A
- Rejected – IK5*R* / AK9*R
Reports, Dashboards, Analytics
An EDI Gateway should provide visibility and transparency into EDI 837 claims, EDI 834 enrollments, and other EDI transaction sets. Typically, the data processed should be stored into a database. Out-of-the-box reports, dashboards, and custom data queries should complete a well-rounded EDI Gateway system.
- EDI operational reports - metrics in nature such as processing time, failed messages, and current running processes
- Business insight reports - claims paid, outstanding claims, encounter management reimbursements, and authorizations to eligibility
- Dashboards – at a glance operational or business status
- Custom data interfaces – pre-built data queries, views, and stored procedures as well as the ability for you to create your own
User Access Controls
For compliance and security reasons, a robust enterprise EDI solution should provide the ability to setup and add granular permissions to users and groups.
Examples of groups are the following:
- Claim Administrators
- Read-Only Users
- Enrollment Administrators
Alerts and Notifications
In a non-perfect world of healthcare EDI processing, something inevitably can happen within your EDI processing. The EDI Gateway platform should be able to proactively monitored with alerts to notify when problems happen.
EDI Alert Notification Trigger Examples:
- Invalid file
- 999 ACK rejections
- Orchestration workflow errors
- Member not found
EDI Gateway systems should also provide application screens that simplify the administration of EDI data processing.
The following are typical features to simplify EDI healthcare processing:
- User and account management
- EDI Trading partner configuration
- Alerts configuration
- Build orchestrations and workflows
- View transaction history and in-process EDI transactions
- Configure rules and policies for EDI SNIP and customized rule sets
- View, edit, and resubmit EDI messages
EDI Gateway for Healthcare
It’s imperative that you consider EDI Gateway systems built and focused on healthcare. There are many EDI platforms out there that were created for supply chain, retail, and logistic EDI industries. Then they try to “shoe-horn” their system into a healthcare solution. Look for an EDI Gateway system that has healthcare focus so that you get industry standard components and compliance out-of-the-box. So many non-healthcare EDI Gateway solutions can’t show you their SNIP Level edit rules. Or, they start to experience extreme performance issues parsing a large monthly 834 enrollment file. That’s because their typical architecture only supports small message payloads like 810 invoices and 850 purchase orders. Typically, companies that purchase these non-healthcare EDI Gateway systems have to implement “workarounds” like splitting, custom rules, and development robs you of ROI quickly.
It’s rare to find EDI Gateway systems that don’t take several months to implement. That’s one of Caliber Health’s differentiating value add – reduce implementations in a non-invasive way. Caliber Health’s EDI Gateway can be up and running with basic functionality in days or weeks – not months! Automation and innovation are two key things that really speed up development and EDI Gateway deployments. For example, a system that can load a sample trading partner EDI file and automate the creation of trading partners and the EDI agreements.
Other Data Formats to Consider
EDI Gateways typically have to handle other healthcare related file processing. These are typically standardized clinical files that take the form in the following ways:
- HL7 – Health Level 7·
- NCPDP – National Council for Prescription Drug Programs
- Proprietary files, flat files
- Other non-healthcare EDI files like the 820
- API web calls
About Caliber Health's T-Connect EDI Gateway
Caliber Health’s EDI Gateway solution was created to simplify the administrative processing for healthcare companies. We are using innovation as a means to provide an industry disruption that makes EDI simple for people and computers. Learn more about our EDI Gateway system here