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