Transcript Qualifacts EDI Project

EDI Project
Adam Davie
Clark Bedsole
Tim Jansen
Robert Jones
CareLogic
 Web-based application created by Qualifacts and
used by health services organizations
 Automates the process of sending patient claims
from health service organizations to payers
(insurance companies, government organizations,
etc.) for approval
CareLogic Interface
Electronic Data Interchange (EDI)
 A standardized method of structuring and formatting
the data exchanged between two entities
 Each payer specifies the EDI file format that health
service organizations must use when sending patient
claims for approval
 Different payers want different information about the
claim
EDI File Transfer
 A batch of claims is assembled by the billing manager
at the health service organization using CareLogic
 CareLogic generates an EDI file of the correct format
from the batch
 The billing manager downloads the EDI file from
CareLogic and then uploads it to the payer’s system
EDI File Transfer
EDI File Format
 The file is broken down into segments and
elements
 Segments represent a collection of information
 Elements are parts of segments and contain
information about the claim
EDI File Format Example
NM1*IL*1*SMITH*JOHN****MI*123456789A~
SV2*0550*HC>G0154*87*UN*2~
HI*BE:61:::9916~
PER|IC|KATHY|TE|5155551212~
Segment Terminator
~
Element Separator
*
Sub-Element Separator
:
Segment
Element
Qualifier
Description
NM1
01
41
Name of Submitter
NM1
01
40
Name of Receiver (Medicare)
NM1
01
IL
Name of Subscriber (Medicare Bene/Patient)
NM1
01
71
Name of Doctor (Attending Physician)
DTP
01
435
Admission Date/Time
REF
01
1C
Medicare Provider Number
System Architecture
 Qualifacts hosts client servers in a data center
 Each server contains a database comprising:
 Patient records
 EDI file formats
 Client accesses database via web interface
 Each client maintains an individual collection of EDI
file format records that reflect the requirements of
payers in their specific locale
 Each client can add, edit, and remove EDI file formats
from its own database
Project Requirements
 Create master library of EDI file formats used by
various health care claim payers
 Create mechanism that enables Qualifacts to apply
changes to the master EDI library
 Add, edit, and delete EDI file formats
Project Requirements (cont.)
 Propagate updated versions of the master
EDI library to each client system
 Master EDI library must be periodically updated
 EDI format specifications change
 New payers with different format requirements are
encountered at client sites
Analysis - Use Case Diagram
CareLogic
Construct Master
EDI Library
Deploy Updated
Master EDI Library
Qualifacts Build Process
Update Client EDI
Library
Manage Master EDI
Library
Qualifacts DB Admin
Client Database
Construct Master EDI Library
 Collect EDI file formats from existing client
databases
 Design table structure
 Each EDI file format is associated with a payer
 Create tables and fill with EDI file format
data
 Segments & Elements
 Separators
Deploy & Update Master EDI Library
 Deploy
 Design mechanism to deploy updated master EDI
library database tables to client systems

Integrate into CareLogic software build process
 Update
 Design code modules that update master EDI library
tables in client databases
 Implement code modules in PL/SQL
EDI Library Deployment System
Manage Master EDI Library
 Design code modules that enable CareLogic to
interface with the master EDI library database
 Add, edit, and delete payers and their EDI file format
requirements
 Implement code modules in PL/SQL
 Integrate new functionality into existing CareLogic
code