EDI HIPAA education

EDI Testing and Approval Requirements (Prevea360 Health Plan)

EDI testing and approval require a minimum of two test cycles and test files. The first test file must be a full population file. This means it must contain all subscribers and dependents currently enrolled in the group for which the test file is being submitted. It is recommend to include a terminated subscriber in this file to accommodate the “Rehire with a gap in their coverage” test scenario in subsequent testing. The second test file must accommodate the following test scenarios. If you are unable to provide all scenarios, please inform Prevea360.

  • New employer/subscriber add with family
  • New dependent add o Change of demographic elements for an existing subscriber
  • Change of demographic elements for an existing dependent
  • Termination of an existing subscriber and family
  • Termination of an existing dependent
  • Change of an existing subscriber’s policy number (2000 loop REF 1L)
  • Rehire with a gap in their coverage
  • Void (Termination – never in effect).

Test File Validation

Prevea360 will review and test all trading partner files with Optum Transaction Testing Service to perform SNIP level validations to ensure that transactions are valid using the following testing categories.

  • Integrity Testing
  • Requirement Testing
  • Balancing Testing
  • Situation Testing
  • Code Set Testing
  • Product Types/Types of Service Testing The EDI team will work directly with trading partner to eliminate all identified validity and scenario errors.

Upon successful test results, Trading Partners will be notified of approval and a mutually agreed upon production go-live date will be established. Production credentials will also be sent at this time.

To learn more about EDI and become a certified  EDI Professional please visit our course schedule page.

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