4 Questions to Ask
Question 2: Can your Clearinghouse validate claims? Can you customize validation to your needs?
Claim validation should be par for the course. Still, many clearinghouses cannot properly validate claims. Much less, health plans are left unable to customize settings that allow for certain transactions while rejecting others. This leads to decreased adoption of auto-adjudication and on-going manual intervention that increases costs and decreases productivity.
SNIP Validation is a common solution for EDI data validation and compliance. There are seven (7) SNIP types and each health plan can tailor type settings to their needs. The right EDI partner works with their health plans to ensure the types are appropriately calibrated and implemented.
This leads to the second question to ask when wondering, “how does my EDI partner stack up?”
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Can your Clearinghouse validate claims? Can you customize validation to your needs?
Ensuring claims are HIPAA compliant and in a valid EDI format before they enter your system is key to streamlining the claims process.
Effective validation reduces administrative workload, mitigates risk of non-compliance, and helps avoid wasted time and provider appeals. SNIP Validation is an important step for pre-adjudication, scalability and profitable growth. Every plan operates at a different level of preparedness. One health plan may be working toward full automation, while another might seek to relieve staff burden to focus on other initiatives. Depending on your systems and goals, an EDI partner can support and modify the validation set-up to support your strategic needs.
- EDI Standard Integrity Testing: Validates the basic syntactical integrity of the EDI submission.
- HIPAA Implementation Guide Requirement Testing: Involves testing for HIPAA implementation guide-specific syntax requirements.
- HIPAA Balance Testing: Involves ensuring that amounts reported in different places add up correctly.
- HIPAA Inter-Segment Situation Testing: Testing of specific intersegment situations described in the HIPAA implementation guides.
- HIPAA External Code Set Testing: Testing for valid implementation guide-specific code set values, as well as other code sets adopted as HIPAA standards.
- Product Type/Type of Service Testing: Ensures that the segments (records) of data that differ based on certain healthcare services are properly created and processed into claims data formats.
- Trading Partner-Specific Testing: The Implementation Guides contain some HIPAA requirements that are specific to Medicare, Medicaid, and Indian Health.