Streamlining EDI processing for leading dental and vision insurer

Client background

The client is a member company of a network providing dental and vision coverage across all 50 states, Washington D.C. and Puerto Rico. 

The business challenge

The client engaged Baker Tilly to identify alternative solutions for simplifying and error proofing the pre-processing of Electronic Data Interchange (EDI) information related to plan member enrollment and eligibility data. The company prioritizes a client-centric approach and aims to ease business processes for their clients. Consequently, they sought to avoid placing the burden of updates and modifications on the dental and vision groups.   

With the implementation of a new group, benefit administration and claims platform, the client faced hurdles that could lead to eligibility failures or incorrect processing, causing unacceptable downstream impacts.

The transition to the new platform introduced challenges, particularly because the client’s group business does not receive unique member identifiers on incoming EDI files. The new administration platform relies heavily on unique identifiers, necessitating the development of alternative solutions.

Strategy and solution

Baker Tilly identified and introduced two possible software companies capable of managing the EDI file pre-processing rules and infrastructure that the client’s chosen platform could not handle. After presenting the options and offering our recommendation, the client selected one of the platforms.

Baker Tilly collaborated with the selected software company and the client throughout the process, managing the workflow, requirements, testing and the implementation timeline. The implementation was completed on time, aligning with the platform solution implementation, resulting in no delay nor any interim manual solutions. The solution successfully met all set-out requirements and adapted to subsequent, unforeseen scenarios.

By stepping in as a trusted partner, Baker Tilly provided software consultation and offered the client effective options and recommendations that ensured success.

Similarly, another member group also faced obstacles in EDI file handling and member data processing. Learn more about the solutions implemented here.