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PREMIUM PAYMENTS

820 PREMIUM PAYMENTS LOAD & RECONCILE

Smart corrections and validation for SNIP L1-L7 & codes

FEATURES

820 PREMIUM LOADER

  • Load 820 files with our scalable Enrollment Loader optimized to handle large load. Enrollment are loaded in Graph Database and available to process in seconds.

  • Trading Partner Setup

  • SFTP File Setup

  • API for Validating and Loading 820 Files

  • L1/L2 Validation of 820 Files

  • Load 820 files with our scalable loader in to Graph DB. Enrollments are loaded in Graph Database and available to process in seconds.

  • Create and send 999, TA1 based on SNIP L1 / L2 Validation results based on the Companion guide configuration. Outgoing 999 is attached to Claims Graph Node and available to audit

  • Run L2-L7 Validation Rules

  • Enrollments data available via API

  • Reconcile with Providers Outbound 820

SNIP L1-L7 VALIDATIONS

  • SNIP L1 / L2 Validation of 820 before loading. Generate error file. The companion guide can be configured by Trading Partner, payer or provider. Companion guides can be changed on fly and tested with incoming files. Fully accept or Partial accept the claims files

  • Custom or out of box companion guide setup for L1/L2 Validations.

  • Configure complex validation and compare rules based 

VALIDATION TEMPLATES

  • Companion guide templates

  • SNIP L1 to L7 rules Templates

  • Compare Codesets, ICD templates

  • Covered and Not Covered template

  • NPI lookup template

  • Other data templates

  • Entire EDI data is available to access via Rest API or configured to stream on Kafka Queues

CLEARING HOUSE INTEGRATION

  • Integrate with HPS

  • Integrate with Availity 

  • Integrate with Change Healthcare

  • Integrate with Office Aly and other clearing houses

GENERATE 820 

  • Generate 820 files

  • Send to various Payers or Providers

  • Create 820 files with our scalable engine optimized to handle large load. Connect to your database to get data and create files and batches

  • Validate the files before sending outbound

  • Manage outgoing Batches / Files Batch outgoing claims in groups and files by receiver. Manage the batch submission and results

  • Receive and Track 999, TA1

820 to MEMBERSHIP AND PROVIDER COMPARE

  • Compare the incoming premium data to membership coverage data at the time of premium payment and identify differences and missed payments by state or CMS

  • Compare inbound Premium payments to outbound vendor and provider membership payments and coverage sent to provides. Validate PCP assignments and changes

SMART AI CORRECTIONS

  • Smart correction on repeating data error

  • Automated AI learning rules to correct data

  • Codes and values to mark for rejections

  • Compare with other file or external data source

  • Audit every correction

  • Manual Corrections via Work queues

  • Auto Correction and Auto Learning - Configure and setup auto corrections of repeating data mistakes by trading partners and providers so that the claim can be processed. Define workflow to hold the claims for specific conditions.

FULL API INTEGRATION

  • Everything in EdiVal is accessible via API. Validation results and 999, TA1  can be accessed via API

  • For Realtime access – Call API with the Payload data.

  • For Batch access, load the file to S3 bucket and call the API with filename. 

  • API response includes EDI Validation Results:

    • 999 Response

    • TA1 Response

    • HTML with error

  • Trading Partner Information  – You can use it to validate Trading partner

  • API are available for access claims, enrollments and all EDI data – validated or errored 

  • APIs are available to run complex query and lookup any data EDI data element

  • Prebuilt mappings, connectors and integration to QNXT, Facets and healthedge systems

  • Get Enrollments API - All the data are loaded are available to access from external systems by get claims RESTful API based on filters like filename, claim id, status - accepted, rejected, all or by claims type, claim date

  • 820 Kafka Server Stream incoming claims data in kafka queue to be accessed by other applications.

SINGLE VIEW OF EDI

  • View Enrollments data on HiPaaS UI. Check the file load status, Check the claims validation status. Volume analysis. Find any claim and claim line items. Drill down on validation error

  • Create missing enrollments via UI 

  • Powerful dashboard gives audit tracing across files and transaction level

  • Plugin any BI tool to write your own analytics

  • Real time visibility to data as it is validated and Loaded

  • Realtime visibility to edi errors and corrections

  • Audit trail of every change

  • Same data view for edi analyst and customer service

NOTIFICATIONS

  • Views and Alerts Setup different business threshold alerts and notify business. Define analysis views by Provider, by trading partner, Submitter and others.

BENEFITS

  • Accurate view of Premium Payments
  • Accurate view of Provider Payments for FFS
  • Accurate and real time Benefits ​
  • Access to care for Members with right membership data
  • Accurate coverage and rate codes
  • Manage dual coverage and overlaps
  • Process retro changes to membership
  • Accurate PCP and premiums
  • Reconcile Premium payments with Eligibility

PREMIUM PAYMENTS

820 PREMIUM PAYMENTS

  • 820 File Validator and Loader

  • Compare Premium files with Eligibility data

  • Compare retro payments

  • Identify discrepancies in premium payments

  • Compare with outbound Provider payments

  • CFO dashboard 

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GET STARTED

Invest your time where it's needed. Set it up once and auto-scale

HIPAAS supports AWS Cloud, Azure or GCP or On-Prem for Enterprise customers. 

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