Common Challenges with EDI 834 Processing Enrollment Teams Face

Common EDI Challenges in the Healthcare Industry

Electronic Data Interchange (EDI) has become a national standard for the healthcare industry to share information with other trading partners. Including member enrollment, benefit inquiry, preauthorization, referrals, claim submissions, claim status inquiry or premium payments, all data exchange between two or more trading partners is performed over an EDI platform.

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About The Author
Nitin Nijhawan, CDOicon

It has become challenging for health insurance companies to keep up with the increasing cost of healthcare and continuously evolving regulatory and compliance norms. Operations teams working with EDI files struggle daily with the EDI challenges in all the areas such as enrollment, billing, authorization, claims and payment reconciliations.

EDI 834 Challenges for Enrollment Team

It’s very important for any healthcare organizations to stay on top of their accuracy and efficiency levels. Whether it’s enrollment for a member from Commercial, Medicare or Individual market segment, the operation team handling the enrollment always runs into challenges during open enrollment, dealing with a high volume of membership data. Any kind of issue faced in EDI systems like receiving bad data from the trading partner, missing data in required fields on enrollment forms or any EDI transactions getting held up in EDI processing systems due to non-compliance of EDI standards can cause a lot of extra work for the enrollment team. It’s crucial for the operation team and EDI teams to maintain the continuous transaction flow especially during the open enrollment window. Any delay in processing can cause disruption for the enrollment of new members, including communication or sending the required welcome kits with ID cards before the policy start date. This can lead to an increased call volume to member services, incurring extra cost to the company.

Data quality is key to successfully enrolling the members.

Especially when working with a new trading partner, it may take a long time for both parties to follow EDI standards and assure accuracy. With more and more companies coming to the market, the number of trading partners that insurance companies have to deal with is also increasing. With the constant increase in data volume and cost of providing quality care and B2B challenges faced with onboarding new trading partners, it has become more important for both parties to conform to EDI standards and maintain fast and quality data communication to keep the costs low.

VLink’s SimplyEDI can help you overcome most of the EDI challenges highlighted in this article that your EDI and Enrollment teams might be facing today.

SimplyEDI can help you easily identify these issues with your EDI 834 enrollment files like format compliance or any missing data in required fields. You can fix the data and re-export the files to continue with your enrollment process. SimplyEDI provides you a very user-friendly view of the cryptic EDI file formats without the need to learn any new EDI file formats or involve your technical teams to interpret the cryptic EDI transactions. You can easily identify the issues with your enrollment file in seconds.

Supported EDI document types in SimplyEDI

• 820 – Payroll Deducted and other group Premium Payment for Insurance Products
• 834 – Benefit Enrollment and Maintenance Set
• 835 – Health Care Claim Payment/Advice Transaction Set
• 837 – Health Care Claim Transaction set
• 270 – Health Care Eligibility/Benefit Inquiry
• 271 – Health Care Eligibility/Benefit Response
• 276 – Health Care Claim Status Request
• 277 – Health Care Claim Status Notification
• 278 – Health Care Service Review Information

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