HEALTHCARE INSURANCE DATA INFRASTRUCTURE: A COMPREHENSIVE ANALYSIS OF EDI STANDARDS AND PROCESSING SYSTEMS
Keywords:
Healthcare Information Systems, Electronic Data Interchange (EDI), Claims Processing Infrastructure, Medical Codification, Healthcare AnalyticsAbstract
This article presents a comprehensive analysis of modern healthcare insurance data processing infrastructure, focusing on the integration of Electronic Data Interchange (EDI) standards and claims processing systems. The article examines the complex interplay between diverse insurance plans, government programs, and provider networks, highlighting the critical role of robust technological infrastructure in managing healthcare data. Through detailed analysis of EDI formats, including professional and institutional claims processing, remittance advice, and enrollment systems, the article identifies key challenges and solutions in medical codification management and member identification. The article explores the impact of post-pandemic healthcare codification changes on processing systems and discusses the emerging trends in healthcare analytics. The article demonstrates the essential nature of advanced computing infrastructure in maintaining operational efficiency while ensuring regulatory compliance. This article contributes to the understanding of healthcare information systems and provides insights for future infrastructure development strategies in the healthcare insurance sector.
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