EDI and Trading Partner Mangement
There are many types of healthcare related data exchanged between trading partners. VISOVA’s trading partner system allows you to define the rules for each of your trading partners and for each specific data exchange format that you employ. A provider typically uses practice management software to submit their billing transaction to a clearing house for routing. Some providers have the ability to create and receive EDI transactions directly, bypassing an intermediary. Standards dictate that an 837 transaction is to be used to submit claims for processing, but VISOVA provides tools to accept claims in proprietary and specialized formats. The trading partner agreements and capabilities of the unique systems that generate these claim submissions vary greatly in content and quality. VISOVA’s Trading Partner Management System, enables you to define the idiosyncrasies with each trading partner and their specific transaction formats so that you can be as forgiving and accepting as possible.
ELECTRONIC DATA EXCHANGES:
- Enrollment data and verification
- Claims submission (Medical, Dental, Pharmacy, etc.)
- Accumulator information
- Payment remittance advice
- Transaction acceptance
- Referrals and authorization
- Premium payments
- ACH/Credit card transactions
- Provider Network Rosters
HIPAA EDI TRANSACTIONS :
VISOVA is designed to be a highly efficient EDI platform with sophisticated search algorithms that automatically find the right provider, patient and plan. As a second step in a single, uninterrupted process, the electronic claim is then sent through auto-adjudication. VISOVA conforms to ANSI ASC X12N versions as required by HIPAA (including ICD10 support). To support returned pricing work-flows, VISOVA retains 100% of the original EDI data presented to you so that it can be returned to the sender exactly as presented to you with re-pricing and message data added. HIPAA Transaction ANSI ASC X12N
- 270 - Eligibility Request
- 271 - Eligibility Response
- 276 - Claim Status Request
- 277 - Claim Status Response
- 278 - Claim Review Request
- 278 - Claim Review Response
- 834 – Enrollment
- 835 - Claim Payment
- 837 - Professional Claim
- 837 - Dental Claim
- 837 - Institutional Claim
- 997/999 - Acknowledgement
BATCH OR REAL-TIME EDI
Transactions can be managed in a batch or real-time processing mode. VISOVA’s trading partner management features allow you to configure specific connections for individual transaction sets. For example: It is common to receive 270 and 276 transactions in a real-time basis allowing the submitter to receive an immediate 271 or 276 response via a secured port. Our port and transaction management software: COMLINK, provides flexible and scalable communication management to bridge the client request to the application resources providing the response.
NON-STANDARD DATA TRANSACTIONS
Accepting non-standard claim formats is a necessary talent and often a source for additional revenue. Impact can accept: CSV, XML, proprietary text, and other data formats. As expected, mapping and configuration resources are often required for these nonstandard formats to meet your trading partner’s schema. VISOVA’s mapping tools and integrated business logic provides your experts the ability to validate, manipulate, and normalize and keep your data clean. It is very common for VISOVA to be the “compromiser” when dealing with trading partners that have the inability to use standards or have difficulties conforming to typical data interactions. (We hate roadblocks to automation… VISOVA helps you break thru those barriers).
DATA SCRUBBING
To enable the highest rates of automation, VISOVA contains a robust suite of demographic scrubbing tools that is founded on USPS rules for addresses and business names. Built on top of that, are the years of self-learning the system has acquired from processing millions of claims, member loads, provider loads, and health care related requests. Clean, consistent data is paramount to all facets of automated business rule processing. VISOVA’s scrubbing rules, combined with IMPACT provider and member de-duping algorithms, keep your data tables fine-tuned for efficiency.
SEARCHING
On a given claim there are many entities represented, such as: Billing Provider, Servicing Provider, Where Rendered Facility, Referring Physician, Insured Members, Patients, Payers, etc. In order to automate most business processes, you need to extrapolate and identify these unique parties so that they can be matched to existing data in your system and apply the rules that you have established. VISOVA allows you to define ranked queries (for each entity on the claim) to be attempted until a perfect match is found or until it is clear that no such perfect match is possible with the data provided. Failing to find these entities; results in manual review, duplicated records, and related inefficiencies. Search statistics are maintained for you to fine tune queries and react to data trends that are found in your population. Certainly, new providers and patients are discovered in the claims process and VISOVA can automate your rules for building providers and enrollment data in your system, where applicable.