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Category Archive for "T-Connect"

TriZetto QNXT – Preprocessing Limitations

TriZetto QNXT is a longstanding leader in Healthcare administration platforms, supporting many lines of business including Medicare and Medicaid.  An important function of QNXT is its strength in claim pricing, member administration and billing management.  However, the provided QNXT toolset lacks flexibility in adapting to new processing requirements.  For example, it would be difficult to perform member lookup and replacement prior to processing through QNXT’s modules.
Understanding the Workflow
QNXT utilizes Microsoft BizTalk Server to intake EDI X12 837 claims and X12 834 enrollments that are utilized in its various modules.  The files are translated from EDI to XML within BizTalk’s native EDI parsing pipeline component deployed as part of QNXT’s ‘QNXT Connect’ BizTalk Application.  The XML is then sent into QNXT where it travels through QNXT’s built-in agents and modules.

However, it is often the case that custom logic is necessary to…

Generate HIPAA EDI Testing Files – 4 Easy Steps!

Need a way to test your systems without compromising patient data? Creating Electronic Data Interchange (EDI) test files from scratch can be an extremely time-consuming option. This leaves many searching for downloadable sample files that often contain only the mandatory loops and hinder the scope of your HIPAA EDI testing.
Fortunately, today’s Healthcare EDI professionals can find an EDI Management Platform to help alleviate their HIPAA compliance headaches.
X12 Studio EDI Toolbox is an EDI development toolkit (available as a free trial download) with a wide range of features that are essential to simplifying the EDI development process. There you’ll find the HIPAA Test File Generator which can generate various sample EDI files, for any healthcare EDI transaction type, in the blink of an eye.
This post will demonstrate how to generate EDI test files in X12 Studio EDI Toolbox

1. The process for utilizing the HIPAA Test File Generator is straightforward. To start, click on the “HIPAA Test File Generator”…

Splitting 835 Healthcare Claim Payment

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…

X12 EDI Databases for HIPAA Transactions

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.
The…

Setting Verbose mode for a Boomi Process using Dynamic Process Property

Setting Verbose mode for a Boomi Process using a Dynamic Process Property
In most instances developers will have to accommodate certain reporting, notification and logging requirements of a given interface within the Dell Boomi AtomSphere platform.
Often times, the logging or emailing may need to be disabled for testing and/or faster iterative cycling through test cases and, of course, to not annoy the user community with email test messages.
The most straightforward way to accomplish or implement a verbose or Test Mode Boolean flag (as is very common in other platforms) is to create and enable a Dynamic Process Property and then assign its default value while allowing to reassign the same with extensions directly after deployment.

Using Dell Boomi Extensions

Dell Boomi provides the concept and implementation of extensions to allow developers and administrators to have distinct values for different environments without having to use multiple connectors of the same type.
As an example in a given scenario where a Dell Boomi Process uses a disk connector to read a file but the file location changes from environment to environment.
EG:
1. Test Server file folder location: C:\TEST\Inbound
2. QA Server file folder location: C:\QA\Inbound
3. Production Server file folder location: C:\PROD\Inbound

B2B Challenges in Healthcare

It’s no secret that paying for healthcare in the United States is extremely difficult to do. Payment systems for healthcare across the country are highly fragmented; many payers and providers use multiple formats for remittance. This creates challenges and frustration for patients, providers, and insurance companies, particularly at a time when there is increased pressure to reduce costs. Other industries use B2B automation processes in standard languages like EDI to standardize and automate payment systems; B2B challenges abound for the healthcare industry.
The B2B challenge in healthcare remittances
Thanks to the Affordable Care Act, there are now in motion some new initiatives related to healthcare payment reform – chief among them, the transition from fee-for-service to value-based care.  “The ramifications of this transition for payers are significant,” says John Tyler, Data Science Platform Manager at Premera Blue Cross. “Payers are going to…

Considerations About HL7 Integration

On the provider side of healthcare integration, HL7 (particularly v2) is a critical message type to understand. While it is standardized and heavily used by various EHRs/EMRs, it’s used in slightly different ways. There are efforts to further standardize and normalize its use across the board (such as with v3/FHIR), many EHRs and EMRs continue to use 2.x messages.  Common HL7 messages include admissions/transfer/discharge (ADT), scheduling (SIU), lab orders and results (ORU, ORM), and medical reports (MDM).  Choosing the right HL7 or EDI Software platform can be challenging.
Some of the challenges of HL7 2.x messages include:

The ability to add non-standard custom segments or additional data anywhere in the message (whether they are completely custom “Z Segments” or other segments that aren’t typically part of the message, such as IN1 segments in an ADT message to include additional insurance information).
A myriad of…

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