EDI Onboarding Process: Trading Partner Setup

The Electronic Data Interchange (EDI) process for onboarding new trading partners to exchange Healthcare EDI files can be performed using files conforming to ANSI X12 specifications. This can be done manually with our FREE EDI Editor download or automatically using an EDI Gateway software solution. These Claim, Payment, and Remittance Advice files may originate from payers, providers, clearinghouses, or third party …

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 …

Solutions to TriZetto QNXT’s Preprocessing Limitations

TriZetto QNXT is a longstanding leader in EDI healthcare administration platforms, supporting many lines of business including Medicare and Medicaid. QNXT is a strong at pricing claims, administering members, and managing billing. The issue comes when there is a need to adapt to new requirements in processing. For instance, it’s difficult to do a member lookup and replace before processing.  …

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 …