The Task:

To develop an application that would help in loading EDI claims, remittance, enrollment / disenrollment eligibility and various kinds of payments into the HMO’s database.

The Challenges:

To process the network of interrelated transactions that take place among the primary care physician, the HMO and the government funding bodies (CMS / ACHA).

The Solution:

Transactions can take place either by proprietary format or electronically. When there is a transaction between the provider and the HMO specific files are exchanged according to their purpose. The following list comes under the EDI files:

For Batch transactions:

• 837 P/I (professional / institutional) – Electronic Claim files
• 835 – Healthcare electronic Remittance advice request form
• 834 – Enrollment and disenrollment for Medicaid eligibility
• 820 – Electronic response files for premium Payments to insurer

For Real time transactions:

• 271 / 272 – Member eligibility request / response
• 276 / 277 – Claim status request / response
• 278 – Authorization and Referrals

Binary Spectrum designed an application where the following sequential course takes place under the EDI claim process:

• Vendor will drop the file in EDI Inbound folder
• Check for compliance and generate 997
• Parse the file for each claim and Scrub into EDI database
• Validate data in EDI’s database against the HMO’s database
• Apply rules for any errors and load those errors’ information into the EDI database
• In EDI Web console, errors will be shown to fix from UI
• Enhance FEE file generation Configurations like
• Generate FEE file as Accepted
• Generate FEE file with errors

 

• Based on the error status/Configurations FEE file will be generated as an acknowledgement
• Loads the claims into HMO’s database (No claim will be loaded into it, until all errors are fixed).

The Result:

The client is effectively using our well framed network for all kinds of claim transactions that takes place. The files that are not in EDI format are processed through Clearing Houses. This facilitates a standard framework for processing.

look at other HMO case studies

1. CRM:
• Managing campaigns, events, leads and enrolling Medicare members
• Managing website portal with regulatory content for compliance
• Standard reports for CMS and Sponsors
2. Medical research administration for Medicare members
3. Online Analytical Processing
4. Health Reimbursement Arrangements

Well if you are interested in outsourcing software development or would like to find out more about our services and offerings, please get in touch with us. You might want to send us a mail, or simply contact us at info@binaryspectrum.com. A senior member of our customer engagement team will get in touch with you within 24 hours.