Most healthcare organizations in the US are required to support the HIPAA transaction set when data is exchanged between payers and providers. Some of the most common HIPAA EDI requirements are:
- Claims Processing (837P / 837I) – support custom validation and routing by trading partner, provider, member ID, provider ID and claim type, service type. Allow for “back-end” legacy adjudication rules to be “consumed” in the EDI channel. Notify providers early in the process if additional information is required to finalize claim
- Enrollment process (834) – support custom employer based rules, work flow queues for exception (over age dependent certification etc.), group and partner specific routing
- Real Time Eligibility (270 Inquiry / 271 Reply) – Exchange of subscriber and member eligibility information including status and health plan benefits
With a large number of commercial tools available, we can help your existing systems support HIPAA transactions. We’ve helped organizations large and small. Give us a call today!