Within my first few weeks at Redox I recall someone talking to me about “835s.” I nodded as if I understood, but I am now secure enough in my job that I freely admit that I had no clue what they were talking about. Perhaps you don’t either.
None of us should feel bad. Unless you are immersed in healthcare administrative and financial data it would be highly unlikely that you would have heard of the X12 transaction set of which the “835” is a part. The X12 organization, chartered by the American National Standards Institute, develops and maintains EDI standards and XML schemas to streamline and facilitate the consistent electronic interchange of B2B transactions across a variety of industries.
The X12N Insurance subcommittee establishes the standards specific to health insurance transactions. Under HIPAA, the US Department of Health and Human Services specifies that HIPAA-covered entities who conduct business electronically must use X12 transactions. X12 is critical for any organization that wants to electronically enroll a patient in health insurance benefits, verify eligibility, get pre-authorization, or request payment for services. They are commonly exchanged between payers, clearinghouses, providers, and more.
While I hesitate to call X12 “old” as I am about the same age, it may be passing the prime of its life. The X12 EDI standards do create more seamless data exchanges than would be present without them, but they are complex and inflexible for developers who are used to working with modern API resources. What’s more, every payer may have slightly different requirements, making it nearly impossible for an organization to have sufficient internal X12 expertise to deal with these transactions at scale.
It is no surprise that many of our customers have expressed they would like to keep X12 at an arm’s length (or many, many arms lengths in some cases). And for our payer and provider customers who must deal with X12, many are looking for ways to easily harmonize X12 with other data sources for ingestion into cloud hosting platforms – supercharging analytics capabilities to identify care gaps and optimize population health, risk adjustment, and/or value-based care programs. We are pleased to announce that we can now make this a reality as we support the exchange of all claims, eligibility, benefit, and prior authorization data in a FHIR format via the Redox API.
Redox helps you simplify your workflows with just one endpoint to receive data from any number of sources including healthcare organizations, payers, clearinghouses, healthcare vendors, and more. You can send and receive clinical, administrative, and financial data (or any combination thereof) in a single, consistent FHIR format. Check out our Prior Authorization case study for an in-depth example of one of these X12 workflows in action, and If you want to get in the weeds, check out our FHIR API References.