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EDI For Benefits Administration

A3logics Assisted Benefits Administrator Scale-up EDI 834 and EDI 837 Processing Capabilities

About Client

The full-service, third-party benefits administrator (TPA) is among the leaders in the self-funded employee benefits health plan category in the US. For its large employer clients, the company handles enrollment, claims processing, COBRA notifications, reporting, and similar duties. Due to the rising market competition, the company is looking to upgrade its benefits technology system by introducing better customization and flexibility options for its customer base - large employers and insurance product owners. TPA is capitalizing upon the plan, utilization and claims data to deliver smart insights to its employer client about how to balance and control their rising benefits costs. In this case study, learn how A3logics helped the client modernize its existing IT capabilities and save costs using its vast experience in EDI healthcare data exchange.

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Business Challenges

Before receiving technical support from A3logics, the client was facing the following issues

The TPA has the responsibility to process claims accurately and timely. For claims processing, eligibility assessment and payer communication, the company was using a decade old system which was becoming slower and less effective in handling issues like flagrant billing, out of network providers, and so on. Manual processes and one-off solutions were unable to support the TPAs’ exponential growth plans. Costs were high and responsive time was becoming poor.

Multiple data challenges were evident in TPA’s existing system due to the frequent onboarding of new employer clients while managing the existing accounts at the same time. Frequent changes by employers in their plan design and network throughout the year were increasing cyclic work. Besides that, the employee enrollment period was putting additional pressure on the IT teams of TPA. Their team productivity was also decreasing.

Besides the usual X12 EDI healthcare data challenges, every customer presented its own set of complexities related to inbound and outbound EDI data. TPA has to accommodate them and maintain the same data quality. With a growing client base, EDI data came in high volumes with varying quality and formats (EDI, CSV, PDFs, Excel, etc.). Phased automation of X12 EDI transactions such as 834 and 837 was ongoing to eliminate manual processes and inefficiencies of legacy systems.

Managing the entire benefits administration and claim processing workflow while maintaining the same, high-quality customer service level throughout the year was challenging for TPA in the highly competitive market. Customer satisfaction level was continuously decreasing towards TPAs’ quality of service.

Due to these bulk of challenges, the TPA and its senior management team were actively looking for a new EDI integration solution that can handle their healthcare data exchange problems and trading partner issues. They wanted an unified solution that can manage the entire X12 EDI workflow - right from benefits plan design, managing applications, checking eligibility to processing and more.

Our Solution

A3logics,a leader in the healthcare EDI domain, has been assigned the responsibility to deliver a data exchange solution that overcomes the complexity and challenges faced by TPA related to X12 EDI data integration. A key selection factor in this engagement was the fact that A3logics has the technology capabilities to support every major healthcare standard - HL7 2.x and 3.x, FHIR, JSON, XML, CCD/CDA, HIPAA X12 EDI - which would guarantee the long-term growth of TPA - no matter how their business evolves. A3logics also promised to extend virtual support for any new standard that arrives in the future.

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A3logics Integration Solution Ensure Speedier and Accurate Data Exchange

Avail benefits of EDI with expert services

Highlights

Powerful Features of Healthcare Integration Solution by A3logics

Accurate and Faster Data Exchange

The benefits administration solution delivered by A3logics allowed the TPA to easily handle the complexities of X12 EDI 834, EDI 837, and NCPDP transactions. This ensures faster, accurate, and secure data exchange with trading partners for your business.

One-Stop Solution

Data integration system from A3logics works as a one-stop tool for managing TPA’s entire customer base (having data from trading partners). Using the single tool, TPA was able to work with multiple databases or repositories to manage inbound and outbound EDI transactions.

Seamless Integration

EDI solution from A3logics automates and streamlines data integration and interoperability for TPA. Integrating with employer systems, internal databases, and employee-facing portals becomes simpler. Rapid reuse of transaction/data formats by TPA help it achieve faster client growth. By adopting A3logics integration solution, TPA applied a single, consistent approach for different types of data integration. Regardless of the type of integration, the process becomes the same. TPA teams needed only one tool regardless of data format.

Intuitive User Interface

A3logics healthcare integration solution has an intuitive interface with visual drag & drop data mapper functions. Incoming data translation, outgoing transaction formation, acknowledgment generation, and process scheduling can be done quickly.

Reporting and Analytics

Getting in-depth insights about the eligibility, enrolled members, claims, and coverage utilization patterns is possible through the benefits administration tool from A3logics. Employers, brokers, and TPAs can easily know about the popularity of different plans and modify them accordingly. In case of TPA, the reporting and analytics capabilities of the system allowed it to deliver insights to employer clients about their health and wellness plan costs .

Seamless Mapping

Integration solution from A3logic identify, flag and/or fix errors, incorrect values and incorrect usage in the incoming EDI data files. The format readers and parsers installed in the system automate the quality check process while ensuring data quality and reliability. Transforming incoming EDI data into desired formats and then routing it to internal systems for claims processing and benefits administration can be done smoothly.

Cost-Effective Solution

Using A3logics integration solution, the TPA was able to save its valuable time and resources. TPA teams were able to shift their focus on serving the customers and improving market reputation. Accelerated data flows between internal and partner applications assisted TPA improve its business relationships with vendors. Data exchange process becoming truly automated and standardized - freeing up TPA teams for focus on other projects and removing backlogs.

Future-Proof Solution

A3logics delivered a future-proof solution to the TPA client that can integrate with any new database, system or application if need arises in the future. Not only that, the system can support all kinds of data format and communication protocols, evident in EDI. It can easily switch between NCPDP, EDI, XML and HL7 and/or any other source/target.

Results

  • 100% error-free data exchange across all insurance carriers and employers for TPA.

  • 40% of cost savings.TPA saved the cost of two full-time resources to manage a single client.

  • 60% reduction in time required for onboarding new employer clients.

  • 12x improvement in turnaround time.

Tools & Technology

  • EDI Technology

  • SaaS

  • Cloud Computing

EDI Standards

The EDI rules and standards set for making documents exchanged for business

  • EANCOM
  • EDIFACT
  • HIPAA
  • HL7
  • IATA Cargo-IMP
  • IATA Cargo-XML
  • IATA PADIS
  • NCPDP SCRIPT
  • RosettaNet

Summary

The given case study highlights the EDI integration expertise of A3logics in the healthcare domain. The custom EDI solutions delivered by A3logics support all kinds of healthcare transactions (EDI 834, EDI 837, EDI 835, etc.) and standards (FHIR, JSON, XML, CCD/CDA, HIPAA X12 EDI, etc.) with complete ease. By leveraging A3logics expertise, TPA capitalized on plan utilization, and claims data to provide the best suggestions to its employer’s clients for controlling their benefits coverage costs. With A3logics, TPA was able to manage their entire customer lifecycle through one integration solution, despite multiple data sources and targets.

The EDI team at A3logics was able to deliver a solution that helped TPA achieve its business objectives and critical customer deliverables. A3logics also extends ongoing support to TPS to develop technical strategies, as well as, implement solutions as new integration challenges arise.

If you’re also looking for seamless data exchange and B2B communication with trading partners in the healthcare domain, contact us at A3logics. Our healthcare integration solutions are used in almost every area of healthcare by insurance carriers, TPAs, benefits brokers, resellers, distributors, employers, and so on. Our expertise in all healthcare standards and transactions makes us the most trusted and top-rated EDI technology vendor among clients.