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EDI: Business to Business Platform for Bulk

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.
B2B EDI Bulk Transactions
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