California Health Care EDI ETL Nghia Phan CS 491B – Software Design Lab Fall 2009

Agenda Background Problems Project Overview 837 and 835 Downloading Feature Overview of Health Care EDI Parsing 837 and 835 Features Project Demo Q&A

Background The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Los Angeles County Department of Mental Health (LA CO DMH) California Department of Mental Health (CA DMH) Information Technology Web Services (ITWS).

Problems No fix schedule from the state on processing 837 and generating 835 ◦ Late payments ◦ Discrepancy Errors in verification of claims and payments ◦ Incorrect payments ◦ Mismatch claim and payment amounts

Problems Common Questions: ◦ Have we submit our claim(s)? ◦ Have we receive our payment(s)? ◦ How many claims that we have submitted for this week, month or year? ◦ How many payments that we have received for this week, month or year? ◦ What are the claims rejected by the state? ◦ …

Project Overview

837 and 835 Downloading Feature Screen Scraping ◦ Capture content of target HTML page ◦ Save the content ◦ Read from the saved content ◦ Filter out target 837/835 download links ◦ Download and uncompress target files into processing location

837 and 835 Downloading Feature

Overview of Health Care EDI ANSI Accredit Standard Committed (ASC) X12 Paper vs. EDI DocumentTransaction LineSegment PhraseComposite Element WordSimple Element CodeIdentifier PunctuationDelimiters GrammarSyntax

Overview of Health Care EDI Segment ◦ Prefix – Purpose of the segment  Example:  ST – Transaction Set Header  NM1 – Submitter Name ◦ Delimiter – Separator of data elements in the segment ◦ Terminate – End of segment (~)

Overview of Health Care EDI Segment Sample CLM* *348.6***11:: 1*Y*A*Y*Y*B**********8  CLM – Health Claim  510… – Claim Submitter’s Identifier  – Monetary Amount

Parsing 837 and 835 Features 837 File Structure 835 File Structure

Parsing 837 and 835 Features

Project Demo Thank you for your patient!!!

Q&A Have a nice weekend and winter break!!!