Eligibility Inquiries Processing through the EDI Channel

The EDI channel receives EDI data (270 transaction) when a submitter (a hospital) uses software that submits eligibility inquires in the form of HIPAA 270 transactions. The insurer and its back-end system are FHIR-compliant and interact through the FHIR server. In this case, XES Module for FHIR converts the HIPAA 270 transaction to the FHIR format and sends it to the insurer. The insurer returns the eligibility response in the FHIR format that XES Module for FHIR converts to a HIPAA 271 transaction.

In this scenario, XES Module for FHIR does the following:

Step 1: A submitter sends an EDI 270 data file with eligibility inquiries. XES Module for FHIR splits the EDI file into individual patient files and converts the EDI data into a FHIR bundle where the EDI information is mapped to the corresponding FHIR resource. For more information, see Eligibility Mapping Rules.

Step 2: When XES Module for FHIR maps data, to simplify eligibility request/response data correlation, XES Module for FHIR creates an identifier for each TRN segment of the original EDI 270 transaction and also assigns its own identifier.

The identifier provided by XES Module for FHIR has the generated value and system = “9EDIFECS  ”.

Example

<identifier>

     <system value="9EDIFECS "/>

     <value value="f0ce5bb9-2843-4811-8efc-61827f42af37"/>

</identifier>

For TRN segments, XES Module for FHIR takes TRN.03 for system and TRN.02 for value:

Example

The following is an example for TRN*1*12345*SUBMITTER1:

<identifier>

     <system value="SUBMITTER1"/>

     <value value="12345"/>

</identifier>

Step 3: Once the eligibility requests are submitted, XES Module for FHIR starts monitoring the CoverageEligibilityResponse FHIR resource associated with the submitted CoverageEligibilityRequest through the request field. When XES Module for FHIR detects a response, it creates the EDI 271 eligibility response. For more information, see Eligibility Mapping Rules.

Step 4: The FHIR eligibility response that XES Module for FHIR receives, can contain any number of identifiers. XES Module for FHIR creates up to three TRN segments in a 271 transaction since HIPAA rules accept up to three identifiers. XES Module for FHIR processes these identifiers in the order they appear in the FHIR CoverageEligibilityResponse resource and creates a TRN segment for each of them until the number of segments is three.