EDI Eligibility Request management
Pega Foundation for Healthcare provides a reference implementation to manage X12 5010 EDI straight-through processing for X12 270 and 271 message transactions – Healthcare Eligibility Request & Response. This capability includes the ability to intake the EDI X12 270 eligibility request message, parse the message according to the EDI transaction implementation guide, create a case, process the eligibility request (leveraging the sample plan benefit eligibility information provided in the sample data), and return an appropriate X12 271 eligibility response message. The functionality can be extended based on your business rules and with appropriate integration with your membership eligibility system.
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