TriZetto QNXT is an end-to-end solution for health plan administration across multiple lines of business. QNXT uses a Microsoft BizTalk Server application called QNXT Connect to intake EDI and translate it into XML for processing; however, transforming an EDI file expands the size significantly. Large files can create a bottleneck causing BizTalk to slow or halt processing. For instance, a 10 MB EDI file can expand to 100 MB after BizTalk translates it into XML. For redundancy, BizTalk also stores that large message repeatedly within BizTalk Server’s database.
There are a few options to resolve performance issues encountered within BizTalk and QNXT system:
Scaling – Upgrading the system by adding additional servers (scaling out) or upgrading existing servers (scaling up). This may solve the problem temporarily but will quickly hit a period of diminished returns as the sheer size of the…
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…
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…
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…