Claim Inbound Profile Overview

When you process business items in complex systems, you may want to be aware of the processing status at each single step. Edifecs XProcess Management allows you to model and monitor cross-enterprise business processes by creating end-to-end models of your business processes and by tracking the phases of your business flow. For more information, see XProcess Management Help Center. This profile shows you how XEServer communicates with XProcess Management while processing various claims by using the route component XPM Event.

Profile Location

Edifecs Library / Best Practices / XProcess Management / Claim Inbound

Requirements

  • Edifecs XEngine 9.0 or later
  • Edifecs XEServer 9.0 or later
  • Edifecs Application Manager 9.0 or later
  • X12 Standard 8.8.11 or later
  • X12N Standard 8.8.11 or later
  • HIPPA Standards 8.8.14 or later
  • External Code Lists for HIPAA 8.8.13 or later

Prerequisites

  1. In Edifecs Application Manager, add the profile Claim Inbound from the Edifecs Library. For more information, see Edifecs Library Help Center.
  2. Double click Configuration, and on the Outline tab, expand Services, and then click Monitoring.
  3. On the Category tab, double-click XProcess Service, and on the Settings tab, establish a connection to XProcess Management by selecting the connection host, and entering the user name, and the password.
  4. Ensure that the connection is successfully established by clicking Test connection.
  5. Click Save () or press CTRL+S to save changes.
  6. Go to the folder ${XESProfile}\bin and run start.bat to start the profile.

Scenario 1

Good Claim Processing

  1. Go to the folder ${XESProfileConfig}\configuration\TestData and copy the sample file MedicaidClaim.dat to the directory ${XESWorkspace}\test-data\inbound.
  2. When the processing is complete, in the Business Item Monitoring section of XProcess Management, you will see two objects - File Processing and Claim Processing. The object Claim Processing contains the following events:
    • Original Claim
    • HIPAA Validated SNIP 1-5
    • HIPAA Validated SNIP 6-7
    • Inbound Business Rules
    • Transformation to Adjudication Format
    • Submitted to Adjudication System
    • Adjudicated
    • End

Bad Claim Processing

  1. Go to the folder ${XESProfileConfig}\configuration\TestData and copy the sample file MedicaidClaim_Bad.dat to the directory ${XESWorkspace}\test-data\inbound.
  2. When the processing is complete, in the Business Item Monitoring section of XProcess Management, you will see two objects File Processing and Claim Processing. The object Claim Processing contains the following events:
    • Original Claim
    • Rejection Ack Sent to Partner
    • End

Scenario 2

  1. Go to the folder ${XESProfileConfig}\configuration\TestData and copy all the sample files to the directory ${XESWorkspace}\test-data\inbound.
  2. When the processing is complete, in the Business Item Monitoring section of XProcess Management, you will see 9 claim objects, each containing the claim state summary and metadata such as:
    • Active
    • ChargeAmount
    • ClaimFileID
    • ClaimID
    • ClaimLOB
    • ClaimReceiptDate
    • ClaimType
    • EncounterReceived
    • isAdjudicated
    • isCommercial
    • isPaid
    • Partner
    • snipError
    • TrackingID
    In the Dashboards section, you can see these 9 claim objects on the following dashboards: