Each day health plan administrators look forward to the challenge of loading 834 enrollments and 837 claims into their adjudication systems.
From a distance, it seems simple to report and reconcile the EDI transactions submitted by providers and clearinghouses through a plan’s intake workflow. Drilling into the steps along the inbounding process, challenges emerge which can present insurmountable obstacles to answering a question as basic as: How long has this claim been held up in my intake process?
TriZetto QNXT is a common adjudication platform we’ll use to illustrate this point. In a typical workflow, loading claims might involve:
Handoff: The day’s 837s are pulled from an SFTP server and moved to the start of the intake process.
Archive: Move files into processing workflow, and archive a copy.
EDI Structural Validation – Basic checks are performed to ensure the 837 transactions are well-formed. This level of validation is…
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…
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…
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.
TriZetto’s QNXT is a widely adopted platform for claim processing and membership administration. QNXT relies on the Microsoft stack, particularly BizTalk, .Net and SQL Server, to process and store EDI messages.
These technologies give developers many tools for customizing and tracking HIPAA transactions, but the complexity of implementing business rules and lifecycle reporting on EDI data are constant concerns for health plan payers.
Tallan’s T-Connect EDI Management Platform is an optimized integration solution founded on three core design principles:
An accessible API. One of the most common challenges our partners face is implementing business logic on EDI. T-Connect loads all HIPAA transactions into a fully compliant hierarchical data structure that can be manipulated with familiar tools such as Visual Studio and .Net.
Full database persistence. Going from EDI to a relational database is a frequent business need, but capturing the full set of fields present in an 837 alone represents…
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 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 parsing and manipulation libraries…
We heavily use the BizTalk Deployment Framework to aid in the deployment of simple to complex BizTalk solutions. One of the greatest benefits is the ability to run custom deployment tasks and scripts. In previous blogs we have shown how to run a custom post deployment scripts in BTDF, today, we will show how custom scripts can be used to conditionally import a binding file during BTDF deployment.
Recently while working on a Biztalk project there was a number of suspended instances that were appearing in the Biztalk Admin Console, after some investigation in to the cause of these suspended instances it was determined that the orchestrations were failing because of uncaught exceptions being thrown from within the orchestration’s exception handlers.
The cause of these uncaught exceptions was eventually tracked down to the following line of code inside of a message construction shape.
To give a little bit of context to the code snippet above, the xmlExceptionMsg object is an orchestration variable of type System.Xml.XmlDocument which is being used to construct a BizTalk message and the LoadXml method is meant to take a string of text which is valid Xml from which that message will be built.
However, it was this method call that was raising the exception that subsequently caused…
I have often run into the same errors in my time developing BizTalk HL7 applications to interface with various HL7 EHR systems. These errors stem from using out of the box BizTalk maps to transform HL7 messages using the Microsoft BizTalk Accelerator for HL7. Here are two of the errors that I have come across that others might have too…