EAI using BizTalk Server & HIPAA Accelerator
The project involves implementation of EAI using BizTalk Server & HIPAA accelerator. Various transactions are implemented to handle different types of messages from different clients. This involved a number of projects for the various APS clients. Each project involved complex logic (business process) implemented using C# (Orchestrations), HIPAA Subsystem implementations, Input/Output XML Schema creations, Data Mapping, Pipeline/Port configuration etc.

CLIENT	HIPAA Transactions implemented
Lufthansa	834 Transaction
Puerto-Rico	820 Transaction
GA_Medicaid	834, 835 & 837 Transactions
MD_Medicaid	835 Transaction
ABRI	837 Transaction
Wyoming	278 Transaction
CHI	837 Transaction
South California Dairy Fund	834 Transaction

IRIS (Integrated Reporting & Information Solution)
IRIS is designed to enable APS users to gather and report on a wide variety of data and offers comprehensive and flexible tracking and reporting capabilities. It supports clinical management of all cases, tracks customer service inquiries and referrals for community services, and manages electronic distribution and collection of vouchers for prompt provider payment. It also provides extensive contract management services to ensure that the administrative and marketing staff provide APS customers with the best service possible. IRIS capabilities include clinical activity tracking (telephonic, face-to-face visits, on-site visits), contract management, marketing activity tracking, community service referrals, collateral contacts, authorization tracking, voucher distribution/management etc. Developed using VB/.Net & SQL Server.

Features:

• Specialized and detailed analysis of healthcare data.
• Electronic submission of provider claims.
• Streamlined data collection.
• Integration of multiple product lines and program areas.
• Rapid membership loads from numerous customers.
• Flexible and comprehensive utilization reporting.
• Internal management level reporting (Management Consultation Module).
  

CCMS Reports
This project involves the creation of approximately 120 reports using Crystal Reports (Crystal Enterprise). Each of these reports are complex and involved developing a number of complex stored procedures to pull out data from SQL Server, and formatting the report as per the specification given by client. Automation of the reports using Crystal Enterprise also involves:

• Emailing the reports to the distribution list
• Placing copy of the report on the Crystal Enterprise web page
• Report On Demand - Placing refreshable report on Crystal Enterprise, so that users can select parameters & rerun as and when required.
• Report outputs are in Excel, PDF, Word & Text

Directories on Demand
This is a web based solution to provide members with on-demand provider directories with up-to-date and accurate information. It extracts the complex PPO/HMO/Specialty network relationships contracted by health plans. Self-funded health plans, insured plans, HMOs and Worker's Compensation payers may contract with up to 50 PPO networks across the U.S. The payers may offer multiple plans, each requiring specific combinations of PPO/HMO/Specialty networks by geography and specialty requirements. The application manages information across these network relationships and produces directories as per the member's search criteria (input parameters).

The features include hard copy, printed booklets, locally printable PDF files, large run remote printable PDF files, as well as query-based online web access (including mobile/wireless) to provider directories. The member can dynamically generate a PDF that can be presented or saved for future references or sent to a remote printing site for mailing.

Appendix-A :
INTRODUCTION TO EDI X12, HIPAA & BizTalk

A.1 EDI X12
Defines a set of rules for electronic data interchange (EDI). The transmission of data proceeds according to very strict format rules to ensure the integrity and maintain the efficiency of the interchange. The X12 family of standards define commonly used business transactions, such as, purchase orders and health care claims, in a formal structure called a Transaction Set. .Each business grouping of data is called a transaction set. For instance, a group of benefit enrollments sent from a sponsor to a payer is considered a transaction set.

Each transaction set contains groups of logically related data in units called segments. For instance, the N4 segment used in the transaction set conveys the city, state, ZIP Code, and other geographic information. A transaction set contains multiple segments, so the addresses of the different parties, for example, can be conveyed from one computer to the other. An analogy would be that the transaction set is like a freight train; the segments are like the train's cars; and each segment can contain several data elements the same as a train car can hold multiple crates. In a more conventional computing environment, the segments would be equivalent to records, and the elements equivalent to fields. Similar transaction sets, called "functional groups," can be sent together within a transmission. Each functional group is prefaced by a group start segment; and a functional group is terminated by a group end segment. One or more functional groups are prefaced by an interchange header and followed by an interchange trailer.

A.2 HIPAA
DHIPAA stands for the "Health Insurance Portability and Accountability Act of 1996". The Centers for Medicare & Medicaid Services (CMS) is responsible for implementing various HIPAA provisions. Macrosoft specializes in the various transaction set implementations in accordance with HIPAA, and has vast experience in "Microsoft BizTalk Accelerator for HIPAA 3.0".

For example the 834 transaction set defines "Benefit Enrollment and Maintenance" for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to establish communication between the sponsor of the insurance product and the payer. Such transaction(s) may or may not take place through a third party administrator (TPA). For the purpose of this standard, the sponsor is the party or entity that ultimately pays for the coverage, benefit or product. A sponsor can be an employer, union, government agency, association, or insurance agency. The payer refers to an entity that pays claims, administers the insurance product or benefit, or both. A payer can be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Champus, etc.), or an entity that may be contracted by one of these former groups. For the purpose of the 834 transaction set, a third party administrator (TPA) can be contracted by a sponsor to handle data gathering from those covered by the sponsor if the sponsor does not elect to perform this function itself.

A.3 BizTalk
Microsoft BizTalk is a windows messaging server system specially designed for application integration:

• Connecting applications within a single organization, commonly referred to as enterprise application integration (EAI)
• Connecting applications in different organizations, often called business-to-business (B2B) integration

BizTalk Server system talks to the heterogeneous System like ERP, CRM, SQL, Web Services, Legacy System etc. Data coming from these systems may have different data formats such as flat file, EDI X12, XML etc.. BizTalk understands and supports a variety of protocols and message formats through various adapters/accelerators and HIPAA accelerator is one of them. Whatever format a message arrives in, it is always converted to an XML document after it is received. Similarly, if the recipient of a document cannot accept that document as XML, the engine converts it into the format expected by the target application.

For BizTalk to analyze and process the messages (to implement the business process), the messages are converted first to a standard XML format and stored in its internal database, called Message Box. This conversion is done by an XML Schema. The business processing logic is called Orchestrations and are created using languages such as C# (these executable code is called Functoids). There could also be data mapping from input message to output message. Each message that resides in the Message Box is picked up by the orchestration for the Processing. . In summary the architecture is depicted below:

For more information please contact:

John Kullmann
jkullmann@macrosoftinc.com
Phone: 973-889-0500 x272