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 …

healthcare edi software Caliber Health

Claim Balancing SNIP 3 for 837s and Post-Adjudicated Encounters

Ensuring that 837 EDI transactions meet validity checks is critical to improving auto-adjudication and encounter submission acceptance rates. SNIP Type 3 describes the rules for balancing header and detail levels of the Claim, Premium Payment and Remittance Advice transaction sets. Previously, our blog covered the logic required to balance 835 transactions. Now we’ll look at the steps necessary to balance claims with service lines, including Coordination of …

Tips for Processing Large EDI Files in QNXT

The Challenge   TriZetto QNXT is an end-to-end solution for health plan administration across multiple lines of business. QNXT uses a Microsoft BizTalk Server application called QNXT Connect to intake EDI and translate it into XML for processing; however, transforming an EDI file expands the size significantly. Large files can create a bottleneck causing BizTalk to slow or halt processing.  …

EDI Validation Software – Free Download | HIPAA 5010 Sets

EDI Validation Software With this EDI Validation Tool healthcare organizations can validate 837 files, 834 files, and other HIPAA X12 EDI file types. The X12 tools are used to test those files by reading, validating, and producing an X12 999 Acknowledgement (ACK). The 999 ACK informs the submitter that the EDI file was valid according to the receiver’s implementation guide.  This x12 …

EDI Testing Files for HIPAA Compliance – Free Download

The best option when EDI testing is to utilize a tool to generate files that meet compliance with HIPAA security regulations. Using sample X12 EDI files for system testing is standard practice for developers and avoids the risk and liability of compromising patient data.  The testing process ensure the ability to transmit files, accept and process response files, and correctly …