EDI Administrator Guide

Overview

As an EDI Administrator, you manage the electronic data interchange between eSHARS and TMHP (Texas Medicaid & Healthcare Partnership). This includes eligibility verification (270/271), billing transactions, and monitoring the automated job processes.

---

Your Responsibilities

Area	What You Manage
Eligibility	270/271 requests and responses
Billing	Billing transaction submissions
Jobs	Monitor automated EDI jobs
Troubleshooting	Resolve EDI failures and errors
Configuration	EDI settings per district

---

Understanding EDI Transactions

270/271 - Eligibility Verification

eSHARS sends 270 request → TMHP processes → TMHP returns 271 response

Transaction	Purpose
270	Eligibility inquiry - “Is this student Medicaid eligible?“
271	Eligibility response - “Yes/No, here are the dates”

Billing Transactions

eSHARS generates claims → Sent to TMHP → TMHP adjudicates → Returns remittance

---

Core Tasks

Task 1: Monitor Eligibility Jobs

Goal: Ensure eligibility checks are running successfully

Steps:

1. Go to Admin → EDI Management → Eligibility
2. Review the eligibility job status:
   • Last run time
   • Records processed
   • Success/failure count
3. Check for errors or warnings
4. Drill into failed records for details

Healthy Status:

• Jobs running on schedule
• Low failure rate (<2%)
• 271 responses received within expected time

---

Task 2: Run Manual Eligibility Check

Goal: Check eligibility for specific students

Steps:

1. Go to Admin → EDI Management → Eligibility
2. Click Run Eligibility Check
3. Select:
   • District
   • Date range or specific students
4. Click Submit
5. Monitor the job progress
6. Review results when complete

When to Run Manual:

• New student added
• Eligibility discrepancy reported
• Troubleshooting specific student

---

Task 3: Review Eligibility Results

Goal: Analyze eligibility response data

Steps:

1. Go to Admin → EDI Management → Eligibility
2. Select Eligibility History
3. Filter by:
   • District
   • Date range
   • Status (Eligible/Ineligible/Error)
4. Review student-level results
5. For ineligible students:
   • Check Medicaid ID accuracy
   • Verify eligibility dates
   • Update student record if needed

---

Task 4: Configure District EDI Settings

Goal: Set up EDI parameters for a district

Steps:

1. Go to Admin → District → EDI Settings
2. Configure:
   • TPI (Trading Partner ID) - District’s TMHP identifier
   • NPI - National Provider Identifier
   • Eligibility Schedule - When to run 270 requests
   • Billing Schedule - When to submit claims
   • Matching Algorithm - How to match students (SSN+DOB, Name+DOB, etc.)
3. Save configuration

Matching Algorithms:

Algorithm	Fields Used	When to Use
SSN + DOB	Social Security + Date of Birth	Most accurate, if SSN available
Medicaid + SSN	Medicaid ID + SSN	When Medicaid ID is known
Name + DOB	First/Last Name + DOB	When SSN unavailable
DOB Only	Date of Birth	Last resort

---

Task 5: Monitor Billing Jobs

Goal: Ensure billing transactions are processing

Steps:

1. Go to Admin → EDI Management → Billing
2. Review billing job status:
   • Last run time
   • Claims submitted
   • Success/failure count
3. Check for transmission errors
4. Review any rejected claims

---

Task 6: Run Manual Billing Transaction

Goal: Submit billing for specific visits

Steps:

1. Go to Admin → EDI Management → Billing
2. Click Run Billing Transaction
3. Select:
   • District
   • Date range
   • Visit status (Ready for Billing)
4. Preview claims to be submitted
5. Click Submit
6. Monitor transmission status

---

Task 7: Troubleshoot Eligibility Failures

Goal: Resolve students failing eligibility checks

Common Failure Reasons:

Error	Cause	Resolution
No match found	Student not in TMHP system	Verify Medicaid ID, SSN, DOB
Invalid Medicaid ID	Incorrect ID format	Correct the Medicaid ID
SSN mismatch	SSN doesn’t match TMHP	Verify SSN with district
DOB mismatch	Date of birth incorrect	Correct DOB
Transmission error	Network/SFTP issue	Retry, check TMHP status

Steps:

1. Go to Admin → EDI Management → Eligibility Errors
2. Review failed records
3. Identify the error pattern
4. Correct student data as needed
5. Re-run eligibility for corrected students

---

Task 8: Review EDI Notifications

Goal: Stay informed of EDI issues

Steps:

1. Go to Admin → EDI Notifications
2. Review alerts:
   • Job failures
   • High error rates
   • TMHP system issues
3. Take action on critical notifications
4. Mark resolved when addressed

---

Task 9: Bulk Move Visits

Goal: Move visits between statuses

Steps:

1. Go to Admin → EDI Management → Bulk Move
2. Select source status (e.g., “Ready for Billing”)
3. Select target status (e.g., “Billed”)
4. Filter visits:
   • District
   • Date range
   • Service type
5. Preview affected visits
6. Confirm the move

Common Bulk Moves:

• Ready for Billing → Billed (after manual submission)
• Denied → Appeals (moving to appeal process)
• DNQ → Ready (after fixing student data)

---

Job Monitoring

Scheduled Jobs

Job	Schedule	Purpose
EligibilityRequestSubmissionJob	Per district config	Send 270 requests
EligibilityResponseProcessJob	After request	Process 271 responses
BillTransactionJob	Per district config	Submit billing claims

Monitoring Dashboard

1. Go to Jobs → Job Status
2. View:
   • Running jobs
   • Recent completions
   • Failed jobs
3. Click into job for execution details

Job Health Indicators

Status	Meaning
Running	Job currently executing
Completed	Finished successfully
Failed	Error occurred - review logs
Queued	Waiting to start

---

TMHP Integration

Connection Overview

eSHARS → SFTP Upload (270/Claims) → TMHP
TMHP → SFTP Download (271/Remittance) → eSHARS

File Types

File	Direction	Content
270	Outbound	Eligibility requests
271	Inbound	Eligibility responses
837	Outbound	Billing claims
835	Inbound	Remittance advice

Troubleshooting Connectivity

1. Check SFTP connection status
2. Verify credentials are current
3. Check file upload/download timestamps
4. Review TMHP status page for outages

---

Reports for EDI Admin

Report	Purpose	Navigation
Eligibility Summary	270/271 activity overview	Admin → EDI Management → Reports
Eligibility Errors	Failed eligibility checks	Admin → EDI Management → Errors
Billing Summary	Claims submission activity	Admin → EDI Management → Reports
Denial Report	Rejected claims analysis	Admin → EDI Management → Reports
Job History	Job execution log	Jobs → Job History

---

Best Practices

Daily Checks

• Review overnight job completions
• Check for eligibility errors
• Monitor billing transmission status
• Review critical notifications

Weekly Tasks

• Analyze eligibility error trends
• Review denial rates by district
• Clear resolved notifications
• Run reports for management

When Issues Occur

1. Check TMHP status first (external issue?)
2. Review job logs for error details
3. Identify affected records
4. Apply fix (data correction, config change)
5. Re-run affected transactions
6. Document resolution

---

Escalation Path

Issue Type	First Contact	Escalate To
Student data error	District Admin	-
Configuration issue	Internal IT	System Admin
TMHP connectivity	Internal IT	TMHP Support
Job failure	Internal IT	Development
Billing discrepancy	Finance	State Admin

---

Navigation Quick Reference

Task	Navigation Path
Eligibility Management	Admin → EDI Management → Eligibility
Eligibility Errors	Admin → EDI Management → Errors
Billing Management	Admin → EDI Management → Billing
District EDI Config	Admin → District → EDI Settings
Bulk Move	Admin → EDI Management → Bulk Move
Job Status	Jobs → Job Status
Job History	Jobs → Job History
EDI Notifications	Admin → EDI Notifications
EDI Reports	Admin → EDI Management → Reports