EDI Webinar Deck - final version (1).pptx

edi

1. Automated Processing of Healthcare EDI Files with Astera WEBINAR

2. How Does EDI Work in Healthcare HIPAA EDI Standards EDI Process Flow in Healthcare Common Approaches for Processing HIPAA EDI Files Challenges associated with each approach Why Astera EDIConnect Use Case-Based Demo Q & A Agenda

3. How Does EDI Work in Healthcare

4. HIPAA EDI Standards EDI Health Care Claim Transaction set (837) EDI Retail Pharmacy Claim Transaction (NCPDP) EDI Health Care Claim Payment/Advice Transaction Set (835) EDI Benefit Enrollment and Maintenance Set (834) EDI Payroll Deducted and other group Premium Payment for Insurance Products (820) EDI Health Care Eligibility/Benefit Inquiry & Response ( 270/271) EDI Health Care Claim Status Inquiry & Response (276/277) EDI Health Care Service Review Information (278) EDI Functional Acknowledgement Transaction Set (997)

5. EDI Process Flow in Healthcare Healthcare Provider Insurance Provider 270 Eligibility check 271 Eligibility check response EDI Health Care Claim Transaction S et (837) EDI Health Care Claim Status Request (276) EDI Health Care Claim Status Request (277) EDI Health Care Claim Payment/Advice Transaction Set (835) EDI Health Care Service Review Information (278) EDI Functional Acknowledgment Transaction Set (997) EDI Benefit Enrollment and Maintenance Set (834) EDI Payroll Deducted and other G roup Premium Payment for Insurance Products (820) Employers

6. Persona: Insurance Provider Receiving Files: From Employers (Third Parties): The insurance provider receives EDI 834 files containing employee healthcare enrollment data. These files include information about newly enrolled employees, changes in coverage, and terminations. From Healthcare Providers: The insurance provider also receives EDI 837 files containing healthcare claims. These files detail services rendered to covered members, including procedures, diagnoses, costs, and payments requested. Use Case

7. Integration and Validation: The insurance provider needs to integrate incoming EDI files seamlessly into their backend systems (like their claims processing or member enrollment systems). Data Accuracy and Compliance: Ensuring that the data in the EDI files is accurate, complete, and compliant with HIPAA. Automation of Workflows: Automating the processing workflows to reduce manual intervention, improve efficiency, and minimize errors in handling large volumes of data. Real-time Updates and Reporting: Providing real-time updates on enrollment statuses, claim adjudications, and financial reconciliations to employers and healthcare providers. Security and Privacy: Ensuring secure transmission and storage of sensitive healthcare information to maintain patient privacy and comply with HIPPA. Onboarding new partners: Efficiently integrating new employers into the EDI ecosystem, ensuring they understand requirements and comply with data standards. Processing Needs

8. Data Inconsistencies & Delays : Manual intervention required for resolving discrepancies leads to processing delays and compromises report accuracy. Inefficient Workflow Management : Delays in data processing and exchange due to system limitations impact operational efficiency and service delivery timelines. Compliance & Approval Rate Issues: Risk of HIPAA non-compliance results in financial penalties, loss of trust, and regulatory scrutiny. Security & Data Integrity Concerns : Ensuring the secure transfer of sensitive data while maintaining data. Data breaches and integrity issues were a major concern. EDI Files Understanding : Staff find it difficult to read and write EDI files, leading to potential errors in processing and data entry. Interoperability : Ensuring compatibility and seamless integration with various systems used by different employers and healthcare providers, each possibly using different EDI standards or versions. Scalability: Struggling to handle large volumes of EDI transactions efficiently, especially during peak periods like open enrollment or times of high claim submissions. Challenges Faced

9. Common Approaches for Processing HIPAA EDI Files VANs (Value-Added Networks) + Home grown solutions/TPAs An EDI Automation Tool like Astera EDI Connect Option 1 Option 2

10. Processing HIPAA EDI Files with VANs

11. Pros Handles EDI transactions between trading partners. Provides some level of data security and compliance. Cons High costs that increase with transaction volumes. Additional fees for exceeding transaction limits. Manual data entry is tedious, time-consuming, and error-prone. Additional fees for adding new partners. Slow onboarding of new partners, often taking months. Uncertain error resolution and support. Limited visibility and control over the process. Processing HIPAA EDI Files with VANs

12. Pros: Custom-built to meet specific organizational needs. No ongoing vendor costs. Cons: Requires significant investment in time and resources. Ongoing maintenance and updates to keep up with industry standards. Requires specialized knowledge and expertise to develop and maintain the system. Processing HIPPA EDI Files with Home Grown Solutions

13. Processing EDI 834 Files with Astera EDI Connect

14. Astera EDIConnect

15. Astera EDIConnect

16. Why Astera EDIConnect ? Code-free operation, no need for EDI format knowledge or technical team involvement. Create detailed trade partner profiles. Faster response times and quicker onboarding with automated workflows. Compliance with standard and custom EDI validation rules. Data translation and mapping. Automatic acknowledgment generation for received EDI messages. Supports various communication protocols (FTP, SFTP, etc.). Build complex EDI transactions with built-in transformations and real-time error correction. Cost-effective for large transaction volumes. Handles increasing transaction volumes and new industry standards. ETL engine for seamless i ntegration with provider s ystems. Automates the entire HIPAA EDI file processing workflow. 24/7 customer support.

17. CCHP used EDI Connect to ensure accuracy and quality in their encounters.

18. CCHP faced inefficiencies in their EDI 834 benefit enrollment process, receiving crucial claim and enrollment data from TPAs in an EDI format ( Encounters) for state reporting and Healthcare Effectiveness Data and Information Set (HEDIS) score determination, necessary for maintaining their Medicaid certification with the State of Wisconsin. High Error Rates: Encounters often had errors, requiring corrections and causing delays. Manual Corrections: Data analysts had to manually copy data files into Excel and use multiple functions to find and correct errors which was time consuming and error prone, Inefficiency : Despite using a TPA for EDI transactions, CCHP had to request correction files for denied Encounters, manually review and correct them line-by-line, and resubmit them to the state. Low Approval Rates : Recurring errors hindered CCHP from achieving the 95% approval rate for State Medicaid EDI data submissions, risking their Medicaid certification and resulting in financial penalties. Before Astera EDI Connect “I would literally need to go in, copy the data file into Excel, and use a number of Excel functions to find and manually correct errors in each file.” – Amanda Moede , Health Plan Data Analyst

19. After Astera EDI Connect Automated Error Correction : Automatically parses, cleans, and verifies EDI files, reducing the need for manual intervention. Data analysts now only need to copy-paste EDI files into the EDIConnect server folder, and the tool handles the rest. Efficiency and Cost Savings: This automation saved CCHP about five weeks’ worth of manual coding and reviewing efforts annually, translating into approximately $26,000 in cost savings. High Approval Rates : Maintained data quality, increasing CCHP's EDI approval rates to 97-98%, exceeding the required 95%, securing their Medicaid-certified status, and ensuring continued state revenue. Improved Workflow : The end-to-end EDI correction system streamlined the entire process, from data parsing and validation to secure transmission to the state, requiring minimal intervention and allowing the data reporting team to focus on strategic tasks. “Each change in the file done manually used to take 3 hours, which would average to about 2 days per month or 192 hours/$6500 per year. Now it takes just 5 minutes. This year, we even get it up to 99%, which is a little unheard of, but we were able to achieve it through the EDIConnect tool. It makes sure that each transaction is compliant and not having to worry about going through each individual error and correcting them one by one in a manual way. On top of the hours and weeks it has saved the data reporting team, it has actually increased our revenue by over $100,000 because of the higher accuracy of data sent to the state. CCHP chose this product in lieu of hiring another person to work on encounter data. Astera has kept our business because the product is easy to work with, can be set up once to be used daily, and can be automated to process files with no intervention. Additionally, the support we receive from their company is high quality.” Amanda Moede , Health Plan Data Analyst at CCHP

20. Any Questions?