Talk to a Supply Chain Expert Talk to an EDI Expert It is used by employers, as well as unions, government agencies or insurance agencies, to enroll members in a healthcare benefit plan. The EDI has been specified by HIPAA standards for the electronic exchange of member enrollment information, including benefits, plan subscription and employee demographic information. Source: entrepreneur. Source: trainingindustry.
Human intervention is one of the biggest issues faced by organizations which also leads to errors. When EDI software or system is unable to manage the complexities and high EDI volume, this manual intervention can result in labor-intensive and hands-on effort. The aim is to ensure the validity of data and that the benefits membership is precise. As some EDI software approaches the as a black box, it is difficult to enable custom enrollment policies and rules. It is complicated and tough to process large monthly files or open enrollment periods.
For the EDI software to process it, manual labor and human intervention are necessary along with complicated parsing methods. There are corrupt or invalid formatted files that must be rejected closer to the intake process. When the entire EDI membership snapshot files are shared for processing, receiver and software logic determines the delta transactions.
Member matching logic is quite important. Hence, the matching algorithm is required to make sure that the membership is correct. Various source systems prepare EDI files and many times, the files are logically out of order which adds to the complexities related to the accuracy of membership records. To understand better, the best example is to try to terminate a member before he was added to the benefits plan. Same as transaction type, there are cases when member records are out of order which has a major impact on the EDI file processing accuracy.
The main issue faced is that dependents are not grouped under the subscriber family. When EDI agencies or companies do not adhere to the X12 ANSI standards, it leads to the increase in processing complexities if the file is not rejected back to the sending partner.
So, you are often left with no choice but to accept invalid standard EDI files and have to fix data variations yourself on the backend. I will keep you posted. No Account? Sign up. By signing in, you agree to our Terms of Use and Privacy Policy.
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