The Electronic Data Interchange (EDI) consists of a file in a specific format that represents data exchanged in a transaction from supply chain to healthcare. EDI 835 Claim Payment transaction provides payments information in reference to claims in EDI 837 Healthcare Claim format. The details include transactions such as charges, deductible, copay, payers, payee, etc. The information is stored a hierarchical structure. The standard of EDI format is well defined and the complexity can be very overwhelming. Additionally, we do not want this high degree of detail slowing our processing time.
One of the problems that enterprise systems face with EDI is file size. A single EDI 835 may contain multiple claim records and the quantity of claims in a single file can make it very difficult to process the file. Systems are often bogged down when dealing with a very…
As we strike out into 2018, the implementation of All-Payer Claims Databases (APCD) across states remains variable and dynamic. Massachusetts maintains a comprehensive implementation, aggregating data feeds from over 80 public and private payers. Massachusetts has leveraged their APCD to create a state-specific risk adjustment model to meet the ACA provision which balances funds from healthier populations to higher risk pools. Late in 2016, Minnesota concluded a feasibility study which determined their APCD could significantly improve risk adjustment vs. the federal model.
On the other hand, West Virginia and Tennessee have put APCD development on hold. California payers optionally submit claims and encounters to a public benefit corporation. Legal, fiscal and political concerns guarantee a fluid situation for insurers.
This blog post is focused on the technical obstacles that health plans face in states requiring APCD submission. Since these databases have phased in over the last decade through both voluntary and legislated…
The X12 HIPAA transaction set is used across the healthcare industry to transmit claim, enrollment and payment information. Given the importance and ubiquity of these EDI files, you might assume that translating them from ANSI to a relational database format would be well-supported with a range of options.
In practice, a task as common as parsing a claim or encounter and storing it in a database can quickly escalate into a significant problem.
One solution we’ve seen involves archiving a snapshot of the EDI file using filestream storage. This can satisfy some retention requirements, but provides little in terms of fine-grained tracking or analytic capabilities.
A more complete approach is to parse the X12 file into its discrete elements and store them in a relational database. The ideal solution captures the full extent of the EDI transactions while also applying a reasonable leveling of flattening to keep in the number of table joins under control.
835 and 837 EDI transactions have transformed the adjudication cycle for providers and health plans over the last two decades, but challenges remain in reconciling payments with claims. Recently, we’ve broken down the requirements for SNIP 3 claim balancing. Today we’ll focus on the 835 Claim Payment/Remittance Advice. Health plans submit 835s to providers (or their intermediaries) to explain which claims are being paid, and any reductions to the submitted amount and the reasoning for the adjustment. This is an important function – a significant pain point experienced by providers is the reconciliation of their income against claims submitted.
Before this valuable information can be loaded in practice management software, the 835 should pass validation checks. Common issues affecting 835s are balancing errors between the header and detail payment amounts. Imbalanced 835s lower the quality of reporting and can lead to billing…
Azure Information Protection allows administrators to define rules to classify corporate data, documents, emails, and other digitally stored information in the cloud, so that the information is protected automatically when the applicable criteria is met in an enforced configuration. Administrators can also set up the configuration so that end users with access to the originating documentation, can have the same options to do so on their own (when optional enforcement is permitted), based on suggestions when criteria matches are found within the sensitive data (e.g. structure of the numbers look like Social Security numbers, patient numbers, credit card numbers, wording in the document using terms like “confidential”, etc.).
Once protection labels are made, applied, and the data is protected, administrators can track the movement of the data and analyze where it flows, where it is stored, copied, shared, etc. This allows you to have a better understanding what kind of behaviors…
Dell Boomi clients wanted to launch new technology capabilities that will rapidly deliver a competitive edge. Unfortunately, project backlogs and multiple priorities often slow the pace of innovation. Overworked and understaffed IT teams often compound this problem, resulting in employee turnover that makes it even harder for businesses to retain the best and brightest IT staff.
Ultimately, the cycle of pressing priorities and strained IT resources leads to a skills gap that causes many companies to lag behind.
And integration is central to this issue. These days organizations need to be extremely agile in how they integrate their applications and data to drive digital transformation. The volume and diversity of integrations necessary for running a digital business are growing exponentially. Social, mobile, analytics, big data, IoT and AI technologies all require integration into core business systems.
And integration is fundamental for any organization…
BizTalk360 is a browser-based monitoring application for Microsoft’s BizTalk integration platform. The out-of-the-box monitoring functionality can be difficult to navigate both for new users and experienced admins, and is complex and time consuming to set up for multiple users with varying access rights. BizTalk360 combines the Admin Console and Event Log, with some added analytical and notification functionality, to create an easy to navigate operational tool.
In this overview of basic BizTalk360 setup, I will assume you have a BizTalk application already deployed that contains at least one receive port and send port. Although there is a huge amount of configuration and monitoring that can be done through BizTalk360, this article will focus on initial configuration and simple environment health monitoring.
One of the great new additions of the recently released Feature Pack 1 for Microsoft BizTalk 2016 is a REST API, which can be used to administer BizTalk Server. Longtime users of BizTalk may have experience with using ExplorerOM.dll or WMI based scripts to manage their BizTalk environment. The REST API introduced in Feature Pack 1 provides a more flexible alternative, including a Swagger definition providing rapid implementation of an application to consume the API. In this post, I will walk through the process of installing the API as well as using Swagger to generate a C# client and demonstrating a simple command.
When the term “big data” first burst onto the scene about seven years ago, experts predicted that organizations could dramatically improve how they operate by capturing and analyzing vast arrays of rapidly growing information.
Fast forward to 2017. It turns out that “big data” wasn’t just another buzzword. Now an established term in the IT and business lexicon, big data is bigger than ever. By some estimates data volumes are doubling every three years.
But organizations have yet to fully capitalize on the value of data for more informed decision-making, operational efficiencies, and personalized systems of engagement with customers and partners.
“Most companies are capturing only a fraction of the potential value from data and analytics,” according to a recent McKinsey Global Institute study, “The Age of Analytics: Competing in a Data-Driven World.”
Connecting Data for Competitive Advantage
For organizations that want to survive and thrive…
Recently, I was met with some friction by the IT department at a client where, they asserted, that a decision had been made years ago to ban Entity Framework. Like many enterprise environments, this client was understandably concerned with the potential pitfalls of embracing Entity Framework. That meant that my job was to convince them otherwise – not to discount their apprehension, but quite the contrary – to demonstrate how EF can be leveraged for its advantages, and avoided for its shortcomings.
Entity Framework (EF) is a broad framework with many optional parts. There are several aspects of EF that provide great benefit, while others are a source of great consternation – particularly from the perspective of the database purist. As the cliché goes, “with great power comes great responsibility,” and so this blog post explores different aspects of EF, and…