Overview:

Implemented Electronic Data Interface (EDI) capabilities in Support of the Affordable Care Act for a Western US Healthcare Payer

Business Issue:

Mid-Size Western Healthcare Payer needed to implement, train and transition the ability to process and reconcile various Electronic Data Interfaces (EDI) files with their State Health Care Exchange, to participate in the Accountable Care Act (ACA) enrollment initiative. Specific EDI transactions that needed to be documented and implemented included Receipt of Enrollment (820), Receipt of Payment (834), and Acknowledgement of Receipt of the file (999).
Soon thereafter the client organization was approved to offer their Qualified Health Plans (QHP) to prospective applicants through their State Exchange, contingent on the client organization’s ability to transact electronically within the timeframes required by the State Exchange.

The purpose of the project was to confirm and align transaction priorities within the timeline provided by the State Exchange implementation schedule, determine the technology that will house the data within the client organization upon receipt, ensure their ability to meet specific requirements for exchanging information, and oversee their technology implementation.

Action:

• Determined current capabilities of the existing technologies to receive, store, edit and reconcile transactions
• Identified and communicated technical modifications that were required to accomplish the above activities
• Defined and documented the requirements for each EDI transaction type, including enhancements and adjustments
• Established acceptable defaults for existing gaps and missing information
• Established testing sequence and prepared sample transactions for testing
• Conducted testing and validation activities
• Identified transition resources to transfer ownership of internal processes
• Conducted knowledge transfer, training, and transition activities

Project Results:

• Implemented all required EDI transactions (820, 834, and 999) within the timeframes established by the State Exchange
• Documented core processes with activity owners in support of the 820/999 and 834/999 transactions
• Expanded client organization enrollment by 34% through the EDI transaction capabilities
• Increased client organization average monthly revenue by $1.1 million (or nearly 50%)