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?”

Ready to jump to all four questions? Want to see how your EDI partner stacks up? Download our white paper here.

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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.

SNIP Types

1. EDI Standard Integrity Testing: Validates the basic syntactical integrity of the EDI submission.
2. HIPAA Implementation Guide Requirement Testing: Involves testing for HIPAA implementation guide-specific syntax requirements.
3. HIPAA Balance Testing: Involves ensuring that amounts reported in different places add up correctly.
4. HIPAA Inter-Segment Situation Testing: Testing of specific intersegment situations described in the HIPAA implementation guides.
5. HIPAA External Code Set Testing: Testing for valid implementation guide-specific code set values, as well as other code sets adopted as HIPAA standards.
6. 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.
7. Trading Partner-Specific Testing: The Implementation Guides contain some HIPAA requirements that are specific to Medicare, Medicaid, and Indian Health.

UHIN is a national EDI network built in 1993 by health plans. We partner with payers and providers across the US. Our approach to EDI and customer service is different. If you’re interest in learning more, please contact us today.

4 Questions to Ask

Question 1: Why are you with your current EDI vendor?

Health plans are often led to believe that healthcare electronic data interchange (EDI) vendors and Clearinghouses are utilities. Just a means to an end. It’s true that utilities – such as water – and EDI vendors both follow regulated protocols and move standardized, secure things.

When you turn on the faucet in your kitchen or bathroom, you expect clean, clear water delivered immediately and at your desired temperature. Often it works perfectly. However, you don’t typically choose where the water comes from or the company who provides water to you. You don’t adjust your settings at an infrastructure level and underlying delivery issues may be well beyond your control.

As a health plan, you can select your EDI vendor, enhance your provider network, adjust settings at an infrastructure level, and get ahead of underlying issues. Beneath the surface, health plans can work with expert EDI partners (not just vendors) to navigate turbulent waters together and deliver seemingly fluid experience and impactful outcomes. This process is understandably daunting despite the increased adoption of automated processes.

For this reason, health plans should ask four key questions to understand the value that their EDI vendor is bringing to the table. Our next four blog posts will cover these four simple, yet critical questions for health plans:

1. With many options out there, why are you with your current EDI vendor? Are they just a vendor in your tech stack or do they serve you as a partner should?
2. Can your Clearinghouse validate claims? Can you customize validation to your needs?
3. Is your provider network frequently contacting you with questions? How does this impact your staff, strategy and budget?
4. How does your EDI partner alleviate the burden of claims submission and simplify your administrative workflow?

Ready to read all four questions now? Want to know how your EDI partner stacks up? Download our white paper here.

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Why Are You With Your Current EDI Vendor or Clearinghouse?

Our first post is introspective. We’ll look at the reasons you may be with your current Clearinghouse or EDI vendor, and how they should serve you to meet the strategic objectives of your department and company as a whole. Keep reading about the way it’s always been, and the futurist approach that health plans should take with a key strategic EDI partner.

The Way Clearinghouses Have Worked

Healthcare EDI networks have been built on vendor relationships that can be daunting and confusing, despite best intentions and the increased adoption of automated processes. Vendors offer “sticky” solutions that can entangle health plans with complicated agreements, abrasive onboarding processes, and technology that may not provide meaningful value.

Today, the essence of a partnership can get lost in the complications of healthcare EDI management. We can shift this paradigm by remembering we’re all in this together – from payers to trading partners, and providers to patients.

So, What Keeps You With Your Current Clearinghouse?

Does your partner simplify administrative burden? Do you have visibility into transactions? Do you receive timely, expert guidance on future X12 standards and HIPAA compliant transactions? An EDI partner should be focused on your holistic operations, and not merely transactions (though they should do those well, too). Perhaps it’s time to rethink the status quo.

If your EDI vendor is not serving you as a partner, you may want to consider what this relationship is costing you.

UHIN is a national EDI network built in 1993 by health plans. We partner with payers and providers across the US. Our approach to EDI and customer service is different. If you’re interest in learning more, please contact us today.