PilotFish EDI Solutions Drive CMS Compliance for Healthcare Payers and Managed Care Organizations

Payers have been impacted by the compliance requirements for Healthcare Payers and Managed Care Organizations (MCOs) in regard to Medicare and Medicaid reporting and CMS Federal regulations. The frequent changes in regulations and reporting requirements have placed a significant financial and time burden on these organizations. To meet these requirements, Healthcare Payers and MCOs must maintain an electronic infrastructure, which is facilitated by EDI technology and systems. PilotFish’s eiConsole for X12 EDI is a modern solution that supports all Medicare and Medicaid reporting and CMS compliance needs, including automating data exchange, validating healthcare X12 EDI data, and supporting non-EDI formats. The solution also includes auditing capabilities and support for compliance reporting, which is mandated by CMS. PilotFish can support several types of Medicare and Medicaid compliance processes, including EDI 837 claim files, EDI 835 remittance advice, CMS-1500, and encounter data.

Over the last few years, the regulatory landscape has drastically changed for Healthcare Payers and Managed Care Organizations (MCOs). Compliance with Medicare and Medicaid reporting and CMS Federal regulations has placed tremendous time and financial burdens on these organizations. Much of the load is due to keeping up with the frequent changes made to Federal regulations and guidelines. Maintaining compliance means constantly adjusting your systems and processes to new rules.

Reporting requirements often change too. Healthcare Payers and MCOs must submit detailed reports for Medicare and Medicaid programs to be reimbursed for services. Generating these reports requires ingesting large amounts of data that must be generated in a specific format for submission to CMS.

Increasingly, to meet reporting and Federal regulation requirements, Healthcare Payers and Managed Care organizations must maintain an electronic infrastructure, which means having an infrastructure in place to support electronic transactions. EDI technology and systems provide the needed electronic infrastructure.

Smaller organizations with minimal reporting requirements may not be using EDI to submit data electronically, but they still must meet all CMS reporting requirements with the proper formatting. This type of submission requires some expertise and usually needs the help of an experienced vendor or a third-party service provider. 

Larger organizations reporting claims data for Medicare and Medicaid require utilizing EDI technology to be more efficient and compliant. Modern EDI software solutions are essential for meeting these requirements. 

Healthcare Payer Workflow Example with the PilotFish Platform

PilotFish’s eiConsole for X12 EDI – the Modern Solution to Meet All Your Medicare and Medicaid Reporting and CMS Compliance Needs

PilotFish’s EDI software and framework support everything associated with Medicare and Medicaid reporting and CMS compliance. PilotFish’s built-in support for X12 EDI is a significant feature that sets PilotFish apart from other integration solutions. This specific EDI support includes comprehensive knowledge of X12 schemas and standards, greatly improving productivity by simplifying the integration process and reducing the need for extensive technical expertise.

PilotFish EDI software helps automate the data exchange between healthcare providers and payers, including Medicare and Medicaid programs. With the PilotFish eiConsole for X12 EDI graphical 7-stage automated interface Assembly Line process and visual drag-and-drop Data Mapper, it’s easy for business analysts to configure, manage and maintain interfaces to facilitate exchanging data. Automation eliminates the need for manual data entry and reduces the risk of errors. Automation also makes it easier to meet compliance requirements, which can be pretty tedious if done manually.

PilotFish’s eiConsole for X12 EDI facilitates validating healthcare X12 EDI data, translating it and mapping it to or from any other application. PilotFish performs validation utilizing a validation processor, which allows you to check for errors and inconsistencies in the data before data exchange. Additionally, it offers a unique level of EDI validation through support for SNIP Levels 1-7 and the ability to test every transaction sent or received for compliance. SNIP 1-4 validation is supported in the base product. Optionally, for those that require it, PilotFish’s eiConsole EDI SNIP4+ offers SNIP 4-7 support. These capabilities significantly reduce the time and effort needed to ensure CMS compliance, resulting in substantial productivity gains.

The PilotFish solution allows you to leverage standardization made possible with EDI technology entirely. Standardized data formats and protocols, such as X12 EDI, are utilized to exchange data between healthcare providers and payers. Standardization ensures that reported data is in a format that Medicare and Medicaid can process and that you can communicate with other trading partners. 

PilotFish does not limit you to just working with EDI data. In addition to EDI, PilotFish supports non-EDI formats and offers any-to-any data transformation capabilities. This support allows easy handling of client healthcare benefit and claims information in any format, including Excel spreadsheets, PDFs, Word documents, email attachments, JSON flat files, CSVs and more. PilotFish also supports all healthcare standards such as HL7 2.x and 3.x, FHIR, CCD, CCDA, DICOM, NCPDP and others. With PilotFish, virtually any standard can be supported using the identical configuration process for integrating Anything into Anything.

Auditing capabilities are also built into PilotFish. Auditing allows organizations to track and review the data that has been exchanged. This data transparency makes it easier to identify and correct errors and discrepancies.

One of PilotFish’s built-in features is support for compliance reporting, which CMS mandates. As a preferred partner of the X12 organization, PilotFish has access to X12 standards artifacts. The eiConsole for X12 EDI supports 5010 HIPAA (the current HIPAA-mandated EDI version), 4010 HIPAA and non-HIPAA EDI.

PilotFish EDI software solutions can support several types of Medicare and Medicaid compliance processes, including:

1. 1. 837 Claim Files: EDI software solutions can generate 837 claim files, which are used to submit claims for reimbursement to Medicare and Medicaid. 837 claim files contain detailed information about the patient, diagnosis, treatment and the charges for the services provided.
   2. 835 Remittance Advice: EDI software solutions can generate 835 remittance advice, which provides payment information and details about any adjustments or denials of claims submitted to Medicare and Medicaid.
   3. CMS-1500: EDI software solutions can generate CMS-1500, the standard claim form used by healthcare providers to bill for services provided to Medicare and Medicaid beneficiaries.
   4. Encounter Data: EDI software solutions can generate Encounter Data, used to submit claims for reimbursement to Medicaid under capitation payment models. Encounter Data contains detailed information about the patient, diagnosis, treatment and charges for the services provided.
   5. Eligibility Verification: EDI software solutions can support EDI transactions such as EDI 270/EDI 271, which allow healthcare providers to check a patient’s eligibility for benefits and coverage under Medicare and Medicaid.
   6. Claim Status: EDI software solutions can support EDI transactions such as EDI 276/EDI 277, which allow healthcare providers to check the status of their claims submitted to Medicare and Medicaid – including the date of payment, amount of payment and any denials or adjustments.
   7. Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA): EDI software solutions can support EDI transactions, such as EDI 823 for EFT and EDI 824 for ERA, which allows for the electronic transfer of funds and remittance advice for claims submitted to Medicare and Medicaid.
   8. Electronic Prescribing of Controlled Substances (EPCS): EDI software solutions can support EDI transactions, such as the NCPDP Telecommunication Standard for EPCS, which allows for the electronic prescribing of controlled substances to Medicare and Medicaid beneficiaries.

PilotFish meets the diverse needs of Payers and MCOs with a modern and flexible system that enables leveraging EDI, HL7, XML standards, web services and Application Server Technology. PilotFish has a long history in the insurance industry. The ACORD standards organization (the HL7.org of the insurance industry) is a long-time licensee of PilotFish products. The PilotFish EDI solution offers the fastest and most efficient way to integrate and exchange data and reports with other payers and Medicare and Medicaid. We facilitate rapid interoperability.

HL7 is the registered trademark of Health Level Seven International.
X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.