Auto-adjudication is an entirely paperless, humanless, process of paying or denying insurance and public benefits claims without having to review each claim manually. Advancements in AI software and other technologies have made auto-adjudication not just possible, but secure. By working through SNIP level validation, it becomes even more safe and secure.
The significant benefits of auto-adjudication include reducing manual tasks, streamlining workflows, eliminating human error with data input, and speeding up the time in which a claim is paid.
Even when fully automated, maintaining high security and being HIPAA compliant is of the utmost importance. So, how can a company maintain HIPAA compliance while shifting to a completely automated system?
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Adjudication for Provider and Member Matching
Some pre-adjudication measures are taken to ensure proper data is matched to avoid errors such as mismatched members or billing errors. Member and provider matching help normalize claims data that can get misread, leading to issues further down the workflow. Normalizing member data will keep systems from matching incorrect data points.
For example, pre-adjudication member matching will help normalize proper names vs. nicknames, i.e., Jenny vs. Jennifer. It also sorts out data points, so members do not get billed against their Social Security Number vs. their Medical ID number.
It’s crucial for billing identifiers like these to be normalized before auto-adjudication. This is where SNIP level validation factors in.
SNIP Level Validation and Edits
SNIP stands for the Strategic National Implementation Process, which was developed by the Workgroup for Electronic Data Interchange. SNIP includes seven guidelines for industry-standard levels of verification when it comes to electronic data compliance.
The seven tests act as a compliance checklist for those in the EDI industry, and they include the following:
- Integrity Testing
- Requirement Testing
- Situational Testing
- Code Set Testing
- Line of Business Testing
- Trading Partner Testing
These levels of transaction compliance testing play a significant role in the development and implementation of auto-adjudication. They create a guideline for maintaining compliance across all levels of the process.
Integrity testing, in particular, is intended to validate each EDI syntax for every specific transaction. In this stage, EDI fields and syntax are tested to ensure valid segments, proper element attributes, and that numeric data has appropriate numeric values. This testing will also involve validating X12 rules and compliance.
The requirement testing level deals with HIPAA-specific fields and requirements. Your EDI processes must be HIPAA compliant across all fronts, so this testing will help weed out duplicate counts, non-medical codes, and situational data not required to process a claim. This testing will also follow X12 guidelines.
To fully implement auto-adjudication, the financial details must be perfected for the system to automatically run claims without error. Balancing testing does just that. It will test the balanced total fields and cover any financial fields in the claims, such as balance summary and total. Without this SNIP edit, you may find yourself facing incorrect balances and billing on auto-adjudicated claims.
Situational testing is one of the most important ways to make sure your claims can be automated without interference. This will test situational fields that cannot adhere to a one-size-fits-all type of automation. This means that if field “A” is present, then field “B” must be present. It is sort of an “if this, then that” situation where your fields are dependent on other fields.
Code Set Testing
Code set testing will ensure all required code sets are readable and accepted during the automated process. This includes ICD-9 codes, CPT-4 codes, etc. You must make sure your systems can read and process each code set appropriately, based on its type and bill those codes correctly.
Line of Business Testing
Each specialty within your healthcare industry will have different requirements for how claims are processed to payers. Whether it is a chiropractor, dermatologist, home hospice care, or another specialty, this SNIP level testing will make sure those forms can be read via auto-adjudication before they ever get implemented with any type of automated system.
Trading Partner Testing
Similar to how different specialties have different requirements for filing claims, the same goes for trading partners. This level of validation can make sure systems are easily figurable to match trading partner requirements for auto-adjudication and claims processing.
SNIP Level Validation and Auto-Adjudication
In short, SNIP level edits and testing are crucial to ensuring your business is capable of auto-adjudication. The claims process is a sensitive one, and without these important guidelines, providers and members could face a slew of billing errors, mismatched claims, and other issues. Testing using the SNIP level edits early on will help fix any issues long before a billing error or missed claim never happens.
Improving processes and increasing auto-adjudication rates is a top priority for us at Smart Data Solutions. Combining SNIP level edits, machine learning, and advanced AI solutions help us to develop streamlined claims processing free of errors and minimal manual processes.
Smart Data Solutions Expert Interview:
What does Smart Data Solutions do in terms of SNIP level validation for their clients?
SDS validates inbound and outbound transactions and has flexible workflow options for every validation level and scenario. Examples include rejecting to the submitter with a 999 transaction, queuing for client review, or accepting with associated reporting.
How early in the development process is SNIP level testing done?
SNIP validation is enabled by default for all new connections and implementations.
Is it necessary to go through all seven levels of testing?
No. SDS can apply whichever level of validation is appropriate for any specific data workflow.