edi project adam davie clark bedsole tim jansen robert jones
TRANSCRIPT
Adam DavieClark Bedsole
Tim JansenRobert Jones
CareLogicWeb-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 approvalDifferent 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 FormatThe file is broken down into
segments and elementsSegments represent a collection of
informationElements are parts of segments and
contain information about the claim
EDI File Format ExampleNM1*IL*1*SMITH*JOHN****MI*123456789A~SV2*0550*HC>G0154*87*UN*2~HI*BE:61:::9916~PER|IC|KATHY|TE|5155551212~
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
Segment Terminator ~
Element Separator *
Sub-Element Separator :
System ArchitectureQualifacts hosts client servers in a data center
Each server contains a database comprising:Patient recordsEDI file formats
Client accesses database via web interfaceEach client maintains an individual collection
of EDI file format records that reflect the requirements of payers in their specific localeEach 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 libraryAdd, edit, and delete EDI file formats
Project Requirements (cont.)
Propagate updated versions of the master EDI library to each client systemMaster EDI library must be periodically
updatedEDI format specifications changeNew payers with different format
requirements are encountered at client sites
Analysis - Use Case Diagram
Qualifacts DB Admin
Qualifacts Build Process
CareLogic
Manage Master EDILibrary
Deploy UpdatedMaster EDI Library
Update Client EDILibrary
Client Database
Construct MasterEDI Library
Construct Master EDI LibraryCollect EDI file formats from existing
client databasesDesign table structure
Each EDI file format is associated with a payer
Create tables and fill with EDI file format dataSegments & ElementsSeparators
Deploy & Update Master EDI Library
DeployDesign mechanism to deploy updated master
EDI library database tables to client systems Integrate into CareLogic software build process
UpdateDesign code modules that update master EDI
library tables in client databasesImplement code modules in PL/SQL
EDI Library Deployment System
Manage Master EDI LibraryDesign code modules that enable CareLogic
to interface with the master EDI library databaseAdd, edit, and delete payers and their EDI file
format requirementsImplement code modules in PL/SQLIntegrate new functionality into existing
CareLogic code