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.