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* A~ SV2*0550*HC>G0154*87*UN*2~ HI*BE:61:::9916~ PER|IC|KATHY|TE| ~ SegmentElementQualifierDescription NM10141Name of Submitter NM10140Name of Receiver (Medicare) NM101ILName of Subscriber (Medicare Bene/Patient) NM10171Name of Doctor (Attending Physician) DTP01435Admission Date/Time REF011CMedicare Provider Number Segment Terminator~ Element Separator* Sub-Element Separator:

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

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