EDI 834 challenges and pitfalls (Caliber Health)
EDI 834 includes vital information that can become a major impact on the sponsor, the payer, and especially the member. Ensuring the EDI 834 file processing goes smoothly is very critical. Here are some EDI 834 challenges and pitfalls Caliber Health have seen over the years.
Common Issues in Processing EDI 834 Files
- Large 834 EDI monthly files – Large monthly files or open enrollment periods can become processing intensive and most EDI software solutions cannot process without manual intervention and complicated parsing methods.
- Manual intervention – In most cases, when the EDI software or EDI parser/validation system cannot handle the complexities and high EDI volume, manual intervention is required an can become a labor-intensive and hands-on effort.
- Not differential – Typically, complete full EDI 834 membership snapshot files are sent for processing. It’s up to the receiver and software logic to determine the delta transactions.
- Variation of the EDI 834 standards – In some instances, EDI capable companies or agencies do not adhere to the X12 5010 834 ANSI standards. This problem increases the complexity of processing if the EDI 834 file is not rejected back to the sending trading partner. In some cases, you are forced to accept an invalid standard EDI 834 file and are left with the task of fixing data variations on the back end.
- Member matching logic – It’s very important to have member matching logic. Some EDI 834 files may contain names or NM1 values that don’t exactly match the system of record. Fuzzy matching algorithms are required to ensure membership is correct.
- EDI 834 membership custom rules – Most companies receiving the EDI 834 files will run their own custom rules to ensure the data is valid and to ensure benefit memberships are precise. It’s too risky to load the file as is. Some EDI software treats the 834 as a “black box” and can be difficult to enable custom rules and policies for enrollments.
- Order of transaction types – An EDI 834 is prepared by many types of source systems. In many cases, the file is logically out of order which increases the complexity and accuracy of the membership records. For example, attempting a terminate before a member was added to the plan.
- Members (subscribers) versus dependents out of order – Similar to transaction types, the member records can be out of order which drastically impacts EDI 834 processing accuracy. A typical pain point is that dependents aren’t always grouped under the subscriber in the family.
- Corrupt files – Invalid formatted files should be rejected as close to the intake process as possible. This ensures that there is no “garbage in, garbage out” data scenarios.
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