Susan McDonald
Management Consultant
Practice Management
Solution Set
 PM Application Services
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Improving EDI Auto-Adjudication Rates for Managed Care Customers
In some cases, claims entry training can take weeks to complete for Managed Care clients. This usually means a number of manual decisions are being made by the claims entry staff, which in turn may convince system administrators that achieving a high auto-adjudication rate via EDI is out of the question. There are, however, some adjustments to configuration that can help make many, if not all, of those "decisions" automatically. Here are a few tricks I've discovered that can improve EDI auto-adjudication rates.
Field Order
Set-up of field order on the EDI processing screen is important, as the system will fill in the fields in the order you determine. The system checks the Branch To, Next Question and Screen Default fields, in this order, to determine what action to apply next. If any of these fields are blank and/or a rule doesn't apply, claims may not be filed cleanly.
Rule Banks
It is possible to call rule banks from the EDI screens for application of custom rules logic to your claims processing. When setting up the fields in a DBMS screen, look for the Programming screen. This is where the call to the rule bank for that table/column reference would be placed. Once the screen is generated, it will be ready to look to your custom rule sets for the proper value.
Non-Dictionary Fields
One can use non-data dictionary fields to "hold" data for making decisions later in the processing. A non-data dictionary field is simply a field that does not file information in to the database. The entries are only used while in a particular form. (This includes fields like "Next screen? Y/N"). For example, the Bill Type field on an inpatient claim actually comes as two separate fields in a standard, HIPAA-compliant file. However, one may have a single field for this on the claims screen. A non-data dictionary field could be used to temporarily hold each piece of the bill type, to make it easier to join them together for filing in the actual Bill Type field. This way, a claims processor will no longer have to enter the correct bill type in the standard field manually.
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