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HIPAA X12 EDI message support

Updated on April 12, 2021
Pega Foundation for Healthcare Product Overview

Pega Foundation for Healthcare provides the ability to intake HIPAA (Health Insurance Portability and Accountability) EDI message transactions for X12 version 5010. The capability includes the intake and parsing of the EDI files based on the Implementation Guides for each message standard. Pega Healthcare applications such as Smart Claims Engine and Pega Care Management leverage the EDI transaction capability for managing inbound claim (X12 837) and authorization request (278) cases respectively. You can leverage the message handling capability to manage the EDI transactions and leverage them in your workflows as needed. Pega Foundation for Healthcare can generate 834 outbound messages from enrollment records, thereby supporting both inbound and outbound 834 EDI related processes. This capability includes multiple member IDs, which can be leveraged for a “key ring” approach to member matching during claims adjudication, and the inclusion of multiple plans on a single policy, to accommodate changes in eligibility during a single plan year.

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