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CLAIMS EDI MANAGEMENT

837 CLAIMS VALIDATION AND LOADER

Smart corrections and validation for SNIP L1-L7 & codes

FEATURES

837 I, P, D CLAIMS LOADER

  • Trading Partner Setup

  • SFTP File Setup

  • API for Validating and Loading Claims

  • Pickup 837 I, P, D Files (837 Institutional, 837 Professional and 837 Dental) 

  • L1/L2 Validation of 837 Files

  • Load 837 files with our scalable claims loader in to Graph DB. Claims 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

  • Generate 277CA based on response of L3-L7 Validation and status from back end adjudication system. Send Denial reason codes. 

  • Claims data available via API

  • Reconcile Outbound 835 ERA

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

  • Manage SNIP L3-L7 validation errors to send to work queues to be worked on by business analyst. Edit the error and Resubmit the claims or reject the claims via 277 CA

  • 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 and 277CA 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 Claims API - All the claims 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

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

  • EDI to FHIR mapping - Prebuilt EDI to FHIR mapping with USCDI US CORE EOB FHIR resources

SINGLE VIEW OF EDI

  • View Claims 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 claims in familiar formats screen Professional (CMS 1500) Institutional (UB-04) and Dental (ADA 2012)

  • 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.

SNIP L1-L7 VALIDATIONS

  • Configure Claim edits-front end rejections

  • SNIP L1 / L2 Validation of claims 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 the rules for Level 3 to Level 7 validations using our front end rules engine. The rules can be applied to trading partner, Sender or globally. The rules can be set to ignore, warning. The rules can call enterprise API services for things like npi lookup, member match and others. The rules also can point to crosswalk tables to check the lookup values.

  • Configure complex validation and compare rules based 

  • Diagnosis Codes, CPT, ICD-10 and HCPCS code set  validations

  • Medicare validation with whats covered and not covered

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 Availity 

  • Integrate with Change Healthcare

  • Integrate with Office Aly and other clearing houses

GENERATE 837 

  • Generate 837 I, P, D Files

  • Create 837 Institutional, 837 Professional and 837 Dental files with our scalable Claim engine optimized to handle large load. Connect to your database to get data and create claim files and batches

  • Validate the files before sending outbound

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

  • Receive and Track 999, TA1, 277CA and 835 ERA

BENEFITS

  • Increase Auto Adjudication Rate
  • Increase Claims Data Quality Rate
  • Reconcile Remittance with Inbound Claims
  • Real time view of work in progress claims
  • Save 30% time on Manual Analysis
  • No Claims Left behind - Account for every claim
  • Timely Response to Providers
  • Transparent view to Providers

CLAIMS MANAGEMENT

837 CLAIMS EDI

  • 837 I, P, D Loader and Validator

  • Generate 999, TA1, 277CA

  • Link 835 ERA, Real time Claims Status 276/277

  • Generate Outbound 837 I, P, D

  • Standard and Custom Edits

  • Automated Data Corrections

  • Simplified Trading Partner onboarding 

  • Simplified Dashboard

  • Integrated with QNXT, Facets, HealthEdge

  • Integrated with Availity

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ENCOUNTERS MANAGEMENT

BENEFITS

  • Submit accurate Encounters to State and Medicare

  • Validate based on State Edits

  • Reduce Encounter rejections 

  • Correct data manual before submission

  • Auto data correction based on state rules

  • Track Encounter responses from state

  • Fix encounter rejections and resubmit

  • Increase acceptance rates > 95%

  • Reduce analysis time by 30% 

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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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