How to get the most out of QNXT

AAJ Technologies

Thursday, November 13, 2014

Introduction

Babar ShahzadMCTS - BizTalk®, MCTS - .Net Framework, MCSD Senior Consultant – Systems Integration

10 plus years experience of working in IT Software development projects. Core specialty is in Systems Integration.

Extensive knowledge about technical functionalities and architecture for fast growing sectors like Healthcare, Banking, Government, Independent Software Vendors.

• What is QNXT

• QNXT Implementation in an Enterprise

• Challenges in Vanilla Version

• Recommendations to achieve the maximum

• Use Cases

• Tools and technologies

Agenda

• QNXT™ is a name and trade mark of product developed by TriZetto

• An administrative system that supports medical and dental claims processing

• Developed using Microsoft technologies with service-oriented architecture

• A configurable and rule driven system

What is QNXT ?

QNXT Implementation in an Enterprise

QNXT(Hosted)

Banks

Fulfillment TP

Trading Partner 2

Trading Partner 1

QNXT (Local)

Legacy Providers Mgmt. System

AHCA/State

Reporting System

Client

Care Mgmt. System

Trading Partner 2

Trading Partner 3

Trading Partner 1

QXI

QNXT Application

Encounters

Trading Partner 3

Data Sync.

Postive Pay

Explanation of Payment (EOP)

ID Cards

Member Letters

Denial Letters

Checks

Provider Letters

837

837ProvidersProviders

Claims Data837 Encounter

Mass Providers Registration

Reports

Authorization

834

834 834834

837

Data

Reports Data

Reports Data

Reports

Challenges in Vanilla Version

• Reporting

• Customization

• Built in business processes

• Built in enterprise workflows

• Integration with internal and external systems

Recommendations to Achieve the Maximum

Challenge Recommendations to Overcome

Reporting Reporting requirement must meet business benefitsConsider to build effective data warehouseUse Custom built reporting tool (e.g SSRS, SSAS etc)

Customization Use existing in house expertise. Best of the breed system

Built in business processes Develop custom processes, decoupled from QNXT, and integrate with it

Built in enterprise workflows Use Enterprise Product like K2, BizTalk etc

Integration with internal and external systems

BizTalk, SSIS, Cast Iron, Mule Soft, Iguana, Mirth

Use Cases

Reports

QNXT

Reporting Services (SSRS)

Members (rdls)

Claims (rdls)

Providers (rdls)

Vendor (rdls)

Care Mgmt. System

Legacy Care Mgmt. System

Legacy Provider Mgmt. System

Trading Partner

State

Internal Business

Users

Systems ClientsReports Hosting

Others (rdls)

Reporting Portal / Scheduled Jobs

Members (aspx pages/Subscription)

Claims(aspx pages/Subscription)

Providers(aspx pages/Subscription)

Vendor(aspx pages/Subscription)

Others(aspx pages/Subscription)

Reports Rendering

Reports Cont…

Name Related ToClaim Aging Summary and Detail ClaimClaim History ClaimClaim Stats ClaimApproved Claims ClaimPaid Claims Summary/Detail ClaimEncounters Status Report ClaimPending Encounter Status Report ClaimRejected Encounters Status Report ClaimCall Resolution MemberMember Utllization MemberReferral Authorization and Referral Authorization Expired MemberMember Import Error MemberMember Data Change Report MemberProvider Utilization Detail ProviderCall Register VendorVendor List Vendor

Membership Enrollment and Maintenance

Care Management System

Extraction

Enrichment

Scrubbing

Validation

Trading Partner 1

Internal Business

Users

Systems Clients/SystemsData Extraction & Preparation

File Creation

File Validation

File Delivery

Reports

File Generation

Trading Partner 2

QNXT

Encounter Process

Extraction

Enrichment

Scrubbing

Validation

QNXT

Care Mgmt. System

Trading Partner

State

Internal Business

Users

Systems ClientsClaims Data Extraction and

Validation

Fixation

837 File Creation

File Validation

File Delivery

835 Response update

Claim Reports

File Generation

Encounters

Encounter Process Cont…

Encounter Process Cont…

Authorizations

Extraction

QNXT

Client 1

Client 2

Internal Business

Users

Systems ClientsMembers Authorization Data

Authorization File Creation

Checksum FileGeneration

File Delivery

Archiving

File Generation

Conversion and Validation

Reports

Checks Data Extraction

CAP Data Claim Data

Logging & Configuration Management

Interface Configuration

Interface Execution Log

Files Delivery

FTP/SFTP

QNXT Custom QNXT PlanData

File Generation

QNXT GUI/Application

Payment Process Execution

Payment Files Generation

Trading Partner

Fulfillment Bank

Payment Process (Checks, Explanation of Payment, Positive Pay)

Automatic Membership Assignment

Member Enrollment

Enroll Member

Assign PCP

Assign GEO location

Assign PCP

Files Delivery

FTP/SFTPFile Generation

QNXT Application

834 EDI file

Monthly Magic Process

Update PCP Assignment

Validation and Logging

QNXT

Validate PCP Assignment

FTP

Conclusion

Thanks