EDI Basics for Health Care

COURSE OUTLINE:

Description This intensive two-day class covers all 9 Health Care EDI Transactions. . The novice will be able to gain knowledge about Health Care fundamentals while the seasoned professional will gain best practices knowledge. The course deciphers all 9 Health Care EDI transactions; every single segment and element of each of the 9 health care EDI transactions will be analyzed and explained. For the most popular transactions there will be a mapping exercise conducted. There will be an implementation best practices section for each of the 9 transactions which will discuss the advantages to be gained and the pitfalls to avoid for each transaction.

Session One: Introduction to EDI
This session defines EDI-its origin, history, and common terminology. It also describes how EDI has evolved over the years to become a globally recognized standard for doing business electronically. You learn the roles of different organizations (X12N and WEDI) that define the Health Care EDI standard. We will also define how different health industry codes (CARC,RARC,ICD-10,CPT,HCPCS) are used in the EDI data. How EDI is used to compose business solutions in different industries (retail, automotive, transportation, etc.) is explained, as well.

Session Two: Components of an EDI Environment and EDI Communication Methods
Communications is a critical area in any EDI implementation. This session emphasizes different options (value-added networks, Internet EDI-AS1, AS2, FTP, etc.) available for moving vital data from one place to another. It also focuses on EDI enveloping and provides a sample scenario of setting up EDI communications with an EDI trading partner. Examples help you gain an in-depth understanding of how an EDI implementation should be integrated with a company's internal network, hardware, security, and software. The second portion of this session is an overview of the personnel, software, and hardware components of a typical EDI setup.

Session Three: Business Analysis and Mapping – Deciphering Health Care EDI Transactions
This session is the bulk of the course and it focuses on the nine Health Care EDI transactions:

  • 270 - Health Care Eligibility Benefit Inquiry and Response
  • 271 - Health Care Eligibility Response
  • 276 - Health Care Claim Status Request
  • 277 - Health Care Claim Status Response
  • 278 - Health Care Services Review - Request for Review and Response
  • 837 - Health Care Claim Institutional, Dental, Professional
  • 835 - Health Care Claim Payment / Advice
  • 834 - Benefit Enrollment and Maintenance
  • 820 - Payroll Deducted and Other Group Premium Payment for Insurance Products
  • CAQH - Core Operating Rules

There will be an implementation best practices section for each of the 9 transactions which will discuss the advantages to be gained and the pitfalls to avoid for each transaction. For the most popular transactions there will be a mapping exercise conducted. All the scenarios, case studies, examples and best practices are from real world Health Care EDI professionals.