Overview

Getting Clean Claims Data In Your Door

Contrary to the belief of many providers, payers do want claims to pass their pre-processing edits so that they can be effectively and accurately processed. There is a substantial cost in attempts to process inaccurate claims data and repeated submissions of claims after rejection.

Providers need to be supported in the process of electronic claims submission so that they can be engaged as partners in improving the quality and effectiveness of this data sharing effort. Presentation and correction of failed electronic claims in a secure, self-service manner offers payers and providers opportunities to reduce re-work and revenue cycle time, and to create better relationships.

Challenges

• Most providers don’t understand EDI technology and are frustrated by communication about failed loops and segments that doesn’t translate to business-understandable language.
• Practice management billing systems vary greatly in their ability to respond to HIPAA and payer-specific claims submission requirements.
• Providers may not be able to process acknowledgements or understand what they need to do to correct claim data errors.
• Payers have limited ability to provide the type of help desk assistance to providers that can rapidly identify and resolve electronic claims issues through a shared view of the claim.

How to Address These Challenges

• Sharing a common portal with the provider and presenting claim data in a way that is easily understandable to the providers is now possible even before the claim has been consumed by the host adjudication system.
• Allowing providers to correct certain errors directly after submission, without resubmission of the claim, can increase the efficiency of processing for both the payer and the provider.
• A business presentation of the EDI data can enable a broader range of potential business users to interact in the claims submission and resolution process.
• Better claim visibility for business users provides an increased sense of control and participation by providers, and enhances provider relationships.

Edifecs Claims Correction

• Edifecs Claims Correction, a business performance management application in the Edifecs Healthcare Suite, provides the solution to address challenges associated with electronic claims submission, rejection, correction and resubmission.
• Using Edifecs Claims Correction’s secure portal, payers may now expose to providers the electronic claims transactions that have not passed pre-processing edits, even before they hit the claims system. Using Edifecs XEngine transaction validation software and the Edifecs Health Transaction Repository (HTR) as core underlying technologies, Edifecs Claims Correction validates claims transactions and stores them in a business-normalized database.
• With this underlying technology infrastructure, the application provides a business friendly view of claims transactions and associated errors. This customizable interface helps the provider easily recognize and understand the errors that are causing the transaction to fail. It also assists the provider in correcting claims by providing valid choices for correction so the provider does not need to search through hundreds of pages of complex implementation guides to find the allowable values.