HIPAA EDI Healthcare EDI Standards

Employers Direct Health Inc. (EDH) a provider of group medical insurance integrated its custom claims processing application with the TradeLink EDI Management System and EDI services provided by SoftCare EC Inc. to automate the HIPAA health care benefits business process from the major Health Care Claims Clearing houses.

Employers Direct Health, Inc., based in Dallas TX, has been in the business of providing group medical insurance to employers since 1960. They have learned one fundamental concept over the past 40 years: If you want it done right, do it yourself. They followed that philosophy to evolve into a fully integrated provider of group medical insurance and related plan design. By being fully integrated, they are able to eliminate the middleman and maximize employer control over employee health care planning and related costs.

EDH was faced with the issue of having to determine what to do with an EDI solution that did not meet their needs EDH had previously purchased an EDI solution to handle the receipt and integration of HIPAA EDI Health Care Claims (EDI 837 – Institutional, and Professional formats) from the major Health Care Claims Clearinghouses. The problem was that the solution could not handle all of the derivations of the standard sent by the clearing houses. In addition, it was felt that the proprietary interface to EDH’s back-end claims processing software was not robust enough to handle the volume or types of documents required to be processed. This led them to look for alternative solutions that could provide the necessary changes while maintaining proper documentation and was maintainable in-house. This led them to SoftCare.

EDH chose SoftCare and its TradeLink EDI Management System because they liked their approach to combining software, consulting and services to provide an all-encompassing solution to implementing EDI for them. Additionally, they were impressed by SoftCare’s focus on EDI, the business processes to support EDI and their open standards based approach to integration to their health care claims system. The first step was to have SoftCare’s Solutions Group work with EDH to understand their business requirements for EDI with each Clearinghouse’s specific needs. This process identified and created a “best practices” EDI implementation for the receipt and integration of each clearing houses Health Care Claim to their back-end health care claims processing system.

The first step in the implementation was to plan out the hardware and software requirements. It was determined that TradeLink was to be installed on a Windows Server 2003 machine and communications to/from the clearing houses would be provided using the existing FTP system that each Clearinghouse had recommended.

Integrating Business Systems to Create a Production Environment

The next step was to have SoftCare’s Solutions Group work with EDH to understand their business requirements for EDI with each Clearinghouse for HIPAA Professional and Instructional Health Care Claims (EDI 837) as they related specifically to EDH’s business requirements. This process identified and created a “best practices” EDI implementation for receipt and integration of Health Care Claims (EDI 837) to their back-end Health Care Claims processing software.

This process was to have SoftCare’s Solutions Group and EDH design and test the business process to move Health Care Claims into EDH’s claims processing system. This process included:

The Solutions Group then implemented the business processes within TradeLink to automate and manage the flow of business documents to their back-end Health Care Claims system from each Health Care Clearinghouse. In the initial testing phase, they relied on TradeLink’s “operations dashboard” and “alert” system, to identify problems with incoming or outgoing business documents and to quickly “resolve” problems with the movement of business documents to/from EDH. Once implemented, TradeLink’s superior audit system was used to manage day-to-day operations of the systems, ensuring a smooth and seamless transfer of information.

Commenting on the overall project, M Jambukesan of EDH’s integrator Vlogic states:

“The implementation has been going great. We have completed Professional and Institutional claims for the main Health Care Clearing houses. The SoftCare Solutions group has been of immense help in the implementation. This year we intend to move all our EDI processes into TradeLink. We would like to recommend your application to any potential client of yours.”.

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