Caliber Health

As a top EDI Solutions provider, Caliber Health offers EDI software and managed EDI services that lower benefits administration costs.

EDI Software Comparison Chart

Compare EDI Software for Healthcare | T-Connect EDI Solutions

Caliber Health

We are often asked about the differences between our T-Connect EDI software solutions.  We offer three solutions: T-Connect SDK, T-Connect Database plus SDK, and T-Connect EDI Gateway.  With all three of these, T-Connect’s powerful processing engine is scalable to millions of claims, enrollments, remittances, and other X12 HIPAA transaction set types. T-Connect SDK for Developers Our SDK solution, provides all of the essentials needed for polling, parsing, translating, validating, and integrating EDI messages.  It’s a complete solution that can be configured to start processing EDI in minutes.  It uses the same underlying components and processing engine as our enterprise grade solutions (T-Connect EDI Gateway).  Our parsing technology is C# .NET, and translates EDI into an object.   Target user: Developers Features: Polling Service, parser, ACK 999, .NET programmable API Processing Capabilities: > 1m supported Technology/Server Requirements: .NET Framework 4.7 or…

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How to Validate EDI 837P Files and Resubmit Corrections

Caliber Health

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…

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X12 Studio – PDF Claim Form Generator Feature

Caliber Health

Exporting X12 837 claim files into standardized CMS1500 or UB-04 forms is simple with T-Connect X12 Studio Toolbox’s PDF Claim Form Generator. CMS1500 is the standardized form for X12 837P (Professional) EDI files.  The CMS1450, aka UB-04, provides the form for 837I (Institutional).  Both forms are provided by the Centers for Medicare & Medicaid Services (CMS). The PDF claim files can be used to view, archive, or manage EDI claims into a human-readable form.  Our Claim Form Generator feature is a very useful tool for EDI Analysts, overlaying 837 EDI data onto industry-standardized forms. Steps to convert EDI 837 files to PDF 1500CMS or UB-04 Forms To start, download X12 Studio and install the application: Launch the application and open an existing 837I or 837P X12 EDI format: Click on the Generate PDF icon in the top menu: View the Output tab…

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Enhanced QNXT Integration – EDI Transformation and Tracking

Caliber Health

TriZetto’s QNXT is a widely adopted platform for claim processing and membership administration. QNXT relies on the Microsoft stack, particularly BizTalk, .Net and SQL Server, to process and store EDI messages. These technologies give developers many tools for customizing and tracking HIPAA transactions, but the complexity of implementing business rules and lifecycle reporting on Electronic Data Interchange (EDI) data is a constant concern for many health plan payers. Caliber Health’s T-Connect EDI Gateway is an EDI software product optimized for healthcare EDI integration and founded on three core design principles: An accessible developer API. One of the most common challenges our partners face is implementing business logic on EDI. T-Connect loads all HIPAA transactions into a fully compliant hierarchical data structure that can be manipulated with familiar tools such as Visual Studio and .Net. Full EDI database persistence. Going from EDI to a relational database is…

Notes from the 2018 WEDI Spring Conference

Caliber Health

The 2018 WEDI Spring Conference mixed deep dives into emerging X12 standards with sessions centered on Open APIs and a greater unification of clinical and administrative data. Here are a few of the topics that jumped out at me, with some thoughts on what these healthcare data trends might mean for our T-Connect EDI Software customers. FHIR – The maturing FHIR standards arguably represent the most dynamic developments in HIT at present. FHIR (Fast Healthcare Interoperability Resources) is set of specifications developed by HL7 that most immediately concerns clinical data in EHR systems, but also extends to the exchange and content of administrative transactions, such as claims and eligibility requests. FHIR is an implementation of modern web standards present in most other industries: RESTful APIs XML and JSON messages OAuth 2.0 as the security mechanism FHIR also defines resources which represent discrete data elements. Here’s a partial view of a FHIR claim…

X12 EDI Databases for HIPAA Transactions

Caliber Health

The X12 HIPAA transaction set is used across the healthcare industry to transmit claim, enrollment and payment information. Given the importance and ubiquity of these EDI files, you might assume that translating them from ANSI to a relational database format would be well-supported with a range of options. In practice, a task as common as parsing a claim or encounter and storing it in a database can quickly escalate into a significant problem. One solution we’ve seen involves archiving a snapshot of the EDI file using filestream storage. This can satisfy some retention requirements, but provides little in terms of fine-grained tracking or analytic capabilities. A more complete approach is to parse the X12 file into its discrete elements and store them in a relational database. The ideal solution captures the full extent of the EDI transactions while also applying a reasonable leveling of flattening to keep in the number of table…

SNIP 3 835 Balancing

Caliber Health

EDI 837 Claim and 835 Payment transactions have transformed the adjudication cycle for providers and health plans over the last two decades, but challenges remain in reconciling payments with claims. Recently, we’ve broken down the requirements for SNIP 3 claim balancing. Today we’ll focus on the 835 Claim Payment/Remittance Advice. Health plans submit 835s to providers (or their intermediaries) to explain which claims are being paid, and any reductions to the submitted amount and the reasoning for the adjustment. This is an important function – a significant pain point experienced by providers is the reconciliation of their income against claims submitted. Before this valuable information can be loaded in practice management software, the 835 should pass validation checks. Common issues affecting 835s are balancing errors between the header and detail payment amounts. Imbalanced 835s lower the quality of reporting and…

SNIP 4 – EDI Intersegment Situational Rules

Caliber Health

WEDI SNIP Types define sets of rules for validating EDI transactions such as 837 claims, 834 enrollments or 835 Remittance Advice. Previously, we’ve blogged about: SNIP 1 & 2 Integrity and Requirement Testing SNIP 3 Claim Balancing SNIP 3 Remittance Advice Balancing SNIP 5 External Code Set Testing This article focus on SNIP 4, which test situational rules spanning separate loops, segments, or elements. What differentiates these rules from Type 2 is that the situational tests span distinct segments, while Type 2 is considered intrasegment testing. Intrasegment tests validate the presence of elements within the same segment based on syntax rules. Type 4 SNIP 4 situational rules break into two categories. Both categories consist of a condition statement, then a data item (loop, segment, or element) which should (or should not) be present based on the rule evaluation. Category 1 The first category of situational…

SNIP 6 – Line of Service or Product

Caliber Health

What are the HIPAA SNIP types available in T-Connect EDI Software products? We get this question a lot, so we’ve been blogging about the different categories WEDI has defined to validate healthcare EDI transactions. Thus far, we’ve covered: WEDI SNIP Levels: SNIP 1 & 2 Integrity and Requirement Testing SNIP 3 Claim Balancing SNIP 3 Remittance Advice Balancing SNIP 4 Intersegment Situational Testing SNIP 5 External Code Set Testing These rules are sometimes referred to as SNIP levels – although that may wrongly imply that each type builds upon the previous category. In actuality, each SNIP type is a standalone set of validations rules. In this article, we’ll focus on SNIP 6. Type 6 SNIP 6 enforces situational rules specific to service lines and products. While SNIP 4 also focuses on situational rules that analyze the relationships between loops, segments and…

Submitting Workers Compensation Claims as 837s

Caliber Health

Workers compensation claims can be submitted in EDI 837 format using a Healthcare EDI Software such as T-Connect. In this article we go over the special set of requirements for these transactions. In a standard 837, the 2000B loop always contains subscriber information (the primary insured individual). Claim level information (2300 loop) is nested beneath the 2000B loop in this scenario. The 2000C (Patient) loop is present in the case in which the claim is related to a dependent of the subscriber. In these cases, the 2300 loop is nested under 2000C. In workers comp claims, a 2000B and 2000C loop always exist, and their purposes are a bit different. Information related to the employer goes into the 2000B loop, while the 2000C loop is used for the claimant (the injured worker). The concept of a dependent doesn’t exist in…