healthcare EDI software

What to look for in a healthcare data solution

Healtcare EDI Software Selection Focus Areas

EDI File Format Compatibility & SFTP Connectivity

EDI Software integrates transaction sets between trading partners and your internal systems. This requires a robust integration framework with EDI connectors, EDI trading partner management, and automated EDI file polling solutions.

  • SFTP Connector – At the heart of any healthcare production system you’ll find a SSH File Transfer Protocol (SFTP) connector is typically provided. For EDI compliance reasons, HIPAA X12 EDI files should be encrypted in transit and at rest. The SFTP is the most reliable and secure protocol available and is typically used between trading partners.
  • File Connector – File system connectors are typically used for non-production EDI testing environments or production EDI solutions that send X12 data for file folder processing. Typically, the file connector is utilized to pass EDI files back and forth without going outside of the company’s network. The file path can be setup as a local path or a shared network path.

EDI X12 Formats and Non-Standard Formats

  • X12 Formats – Be able to handle the complete 5010 X12 transaction set. That includes EDI 834 Benefit Enrollments, 837I Institutional claims, 837P Professional claims, 837D Dental claims, 835 Remittances, 270 / 271 Benefits Eligibility, 820 Remittance Advice, 999 Acknowledgements, 277CA Claim Acknowledgements, and 276 / 277 Claim Status.
  • X12 Post Adjudicated Formats – New transaction sets have been released specifically for post-adjudication processing to CMS and the states. The EDI 298 Post Adjudicated Professional Claim, EDI 299 Post Adjudicated Institutional Claim, and EDI 300 Post Adjudicated Dental Claim align with but are different than the Claims 837I, 837P, and 837D EDI schemas.
  • Proprietary Formats – Healthcare EDI software platforms should also support non-standard transaction types. Those file types are typically translated into and from an EDI file format. This may include XML, Flat File, Excel or CSV files, and JSON payloads.

EDI Workflow Automation

A modernized EDI solution should be able to contribute to business process automation by automating the workflow of EDI files and processes.

Example: EDI Automation – Inbound Healthcare EDI Workflow

  1. Poll for a specific trading partner’s inbound files using a connector on a configured time interval (for example, every 30 seconds)
  2. Pick up data file and begin processing
  3. Parse EDI files against the corresponding TR3 schema
  4. Validate EDI files and respond with a 999 acknowledgement (ACK). The 999 ACK transaction will outline if the file was accepted and any validation issues occurred. The system should automatically send the 999 ACK back to the trading partner
  5. Enrich, transform, and run rules
  6. Send results to the destination system for processing

Figure 1: EDI Workflows – Example Healthcare EDI 834 Workflow

edi software

EDI Transformation & EDI Mapping

Transformations and maps are critical for integrating in healthcare. Commonly, a transformation is needed when the source and destination file have different schemas or data elements. There are many patterns to implement for transformations, but the two main data mapping patterns to look for are Point-to-Point and Canonical.

  • Point-to-Point Mapping Patterns – Source file “A” with schema “A” is directly mapped to Destination File “B” with schema “B”. This is referred to point-to-point and provides no reusability patterns; however it’s simple and usually has better performance.
  • Canonical Mapping Patterns – This pattern utilizes a canonical schema that acts as the central and reusable data schema. The idea is to reuse pre-built canonical maps and simply plug in additional new schemas. This promotes agile partner and system onboarding but is much more complex to implement. An solution should provide the basic capabilities out-of-the-box and streamline these mapping patterns.

Figure 2: EDI Mapping Patterns – Canonical Mapping Vs. Point to Point Mapping

EDI Mapping Comparision

HIPAA EDI Processing Compliance

Healthcare companies must be Health Insurance Portability and Accountability Act (HIPAA) compliant. The U.S. Department of Health and Human Services (HHS) lays out the HIPAA Data Privacy Rule to protect patient identifiable health information. The Healthcare EDI files contain this sensitive data and must be treated with the highest degree of security, trace-ability, and principles. EDI gateway platforms must be able to support data security, user access security, and platform security.

X12 EDI Standards

The handling X12 EDI files for healthcare must comply with the X12 5010 standards. The X12 organization is an American National Standards Institute (ANSI) chartered non-profit that develops and sets standards for EDI data transmission. Meeting these standards is critical to efficient global information exchange.

Standardized WEDI SNIP Rules

What is WEDI SNIP? SNIP is short for the WEDI SNIP (Workgroup for Electronic Data Interchange Strategic National Implementation Process). Caliber Health is a proud member of the WEDI organization, formed in 1991 by the Secretary of Health and Human Services (HHS) as a respected authority on the improvement of healthcare information exchange. Healthcare IT professionals are encouraged to attend their annual events and review our WEDI Conference Notes for additional healthcare IT insights.

When it’s time to Compare EDI Software, look for solutions that are built FOR HEALTHCARE and not shoe-horned from the more generalized logistics or supply chain systems. This ensures your system meets the, X12 standards, HIPAA compliance requirements, and SNIP rules sets of a true healthcare EDI Gateway. SNIP level edits provide the basis of validating industry standardized rules on seven levels.

WEDI SNIP Validation: The 7 SNIP Level Edits

  • SNIP 1: EDI Standard Integrity Validation
  • SNIP 2: HIPAA Requirements Validation
  • SNIP 3: Claims Balancing Validation
  • SNIP 4: Inter-segment Situational Validation
  • SNIP 5: External Code Set Validation
  • SNIP 6: Type of Service/Product Validation SNIP 7: Trading Partner Specific Validation

At the minimum, your system should support SNIP 1 and 2. This verifies that the EDI file is structurally and syntactically correct. EDI Software vendors should be able to show you their SNIP rule level edits within their software. Believe it or not, some of the major industry leader software companies don’t have the minimum SNIP levels 1, 2.

Custom Validation Rules for EDI files

A custom set of rules is typically required above and beyond the standardized WEDI SNIP rules. In many cases, healthcare companies require additional business rules on top of the standard SNIP edits. For example, checking for duplicate claims in a file, running member fuzzy matching logic, and providing rule-based data element enrichments.

EDI Data Visibility & Analytics

Most solution companies treat EDI as a transient data workflow. They are not typically a robust EDI data storage solution to enable EDI transaction visibility and EDI data analytics. Look for back-end database features that are easy to work with and systems that provide out-of-the-box reports, tracking, and analytics.

Batch vs. Real Time EDI Processing

Most EDI Vendors should support both batch and real time processing modes. Typically in healthcare, there are only a few transaction sets that are processed in real time:

  • 270/271 – Real Time Eligibility: Reducing administration costs by providing an application interface that allow providers to verify eligibility prior to submitting claims. This reduces claim rejections and provides lower write-offs from payers. Quality Healthcare EDI platforms should offer the option to add-on a real time 270/271 software module to power this back-end processing functionality.
  • 278 – Referrals and Authorizations: A healthcare focused data solution can provide real time application services for accurate and timely benefits authorization. Pre-authorizations also reduce administration resources in an efficient automated application.
  • 276/277 – Claim Status and Inquiry: A means to verify claim’s status after submission.

Ask your EDI software provider if they provide real time transaction support and if they are CORE/CAQH compliant. Since Caliber Health is a CORE Certified software vendor, we are happy to share some CAQH Core Certification Tips.

CAQH Core Certified EDI Software Vendor

EDI Trading Partner Onboarding

For most healthcare companies, trading partner configuration and onboarding is key to integrating with partners outside of their company. Look for modernized and innovative EDI solutions to automate the configuration of trading partners.

Normally, the EDI trading partner configuration is based on your partner’s companion guide (or EDI implementation guide). If your company hosts the companion guide, then your trading partners need to perform the translations to meet your specifications.
The trading partner configuration is typically pulled from the EDI outer envelope ISA/ISE and GS/GE segments.

Additional Considerations

  • Data Ownership and Control - Purchasing and installing EDI Software gives you complete ownership of the solution. This may be a paramount concern for EDI healthcare companies who rely on intermediaries for changes. Additionally, companies that have already invested in EDI developers, EDI analysts, and infrastructure typically lean towards system ownership options.
  • Healthcare EDI Customization – If installed within your network it should not be a “black box” solution. In most instances, customer customization is required to meet specific requirements and use cases. Choose a solution that is geared towards pre-built healthcare logic and is easily customizable.
  • IT Requirements - Installing into your data center requires IT resources and dedicated staff to host the solution. It’s a common in the healthcare industry to have moved to virtual machines (VM). Cloud hosting options are now becoming the popular way to host EDI software. Popular HIPAA compliant cloud providers include Amazon and Azure.
  • Staff Requirements - EDI is very complex and requires the right mix of software product and EDI staff. Hiring the right EDI developers, EDI managers, and EDI analysts are critical to making your project a success.
  • Modernized and Innovative - As you compare EDI software, look for solutions that are focused on healthcare and are using the latest technology innovations, The days of parsing EDI into XML is long gone and old technologies cause major performance issues and are difficult to administer. Our healthcare integration consulting background provides Health Plans with useful tips for loading large EDI files into QNXT.

Ownership Alternatives

Hosted EDI Software

Hosted options abstract the server, network, and all necessary components in a ready-to-use cloud hosted environment.

Managed EDI Services

Managed EDI Services offerings should provide white glove services that manage every aspect of implementation and support. Checkout our T-Connect Managed EDI Services offering for more information.

Get Expert Healthcare EDI Software Advice

Caliber Health provides .NET developer friendly C# APIs to power the health data solutions of benefits payers, data analytics providers, 340B data managers, and third-party administrators.

Healthcare data processing technology can enhance your team’s EDI capabilities. Get the most out of your data with healthcare 5010 benefits data tracking, reporting, storage, and compliance. Bring us your EDI development challenges, we’ll provide the framework and expertise to bring your competitive advantage vision to life. Our proven products are built for unmatched EDI parsing and data ingestion speeds. We’ve done the heavy lifting for you, with 1,000’s of hours spent developing and optimizing T-Connect EDI Databases. If your organization provides software or services to providers, we have the EDI engine to power your solutions. Our software processes 837 Claims, 834 Enrollments, and all other HIPAA 5010 transaction sets with unbelievable speed and accuracy. Let’s get your developers off on the right foot with a proven solution that is designed to be leveraged by both developers and managers.

Caliber Health can get you started quickly with a product option that fits your needs and business.
See our compare EDI software page to explore the features of our T-Connect EDI  software products and contact us for more information.