Processing of 837 EDI with NPI and Backend Selection Profile Overview

The processing of EDI files often requires the building up of a set of complex logic steps, for example:

  • Selecting a suitable data flow on the fly based on NPI, Subscriber ID, or other values.
  • Generating appropriate acknowledgements and sending them to the back-end processing systems.

Each of the back-end systems often use their own formats of data (not EDI), so you require an additional step for translation between the formats. This profile serves as an example of a flow and shows you how to use some helpful Edifecs functions, such as:

  • XEServer Batcher: to batch Acknowledgements.
  • XEServer Balance Counters: to ensure the integrity of the processed data.
  • Edifecs Crosswalk: to select the back end destination on the fly.
  • Edifecs Visualizer Server: to visualize the processed results and the attendant information.

Profile Location

Edifecs Library / Best Practices / HIPAA Interactions / Processing of 837 EDI with NPI and Backend Selection

Requirements

Edifecs products

  • Edifecs XEngine 9.0 or later.
  • Edifecs XEServer 9.0 or later.
  • Edifecs Application manager 9.0 or later.
  • Edifecs Visualizer Server 9.0 or later.
  • Edifecs HIPPA Standards 9.0 or later.
Other
  • MS SQL or Oracle database

Prerequisites

  • In Edifecs Application Manager, add the profile Processing of 837 EDI with NPI and Backend Selection from the Edifecs Library. For more information, see Edifecs Library Help Center.
  • Set up the Balance Counters groups. You can do this by deploying the corresponding Balance Counters configuration that comes with the sample profile. Once you add the profile, you can find the configuration at ${XESProfileConfig}/configuration/OuterConfigurations/.
  • Set up the Batcher configuration. You can do this by deploying the corresponding Batcher configuration that comes with the sample profile. Once you add the profile, you can find the configuration at ${XESProfileConfig}/configuration/OuterConfigurations/.
  • Establish a connection to the database for Balance Counters and Batcher.
Visualizer Server
  • If you plan to use Visualizer Server (you can still run the sample profile without using Visualizer Server), do the following:
    1. Set the XEServer environment property VisualizerEnabled to true.
    2. Create the HIPAA 837, 005010X222A1 Visualizer Server data store and the dashboard.

    If you do not plan to use Visualizer Server, do the following:

    1. Set the XEServer environment property VisualizerEnabled to false.
    2. Disable the XEServer route under the Visualizer folder.
    3. Disable the XEServer Visualizer Reporter Service.

Test 1: File System Backend

The target adjudication system is a local system.

  1. Start the profile. Verify that all the required routes have been started.
  2. Copy the sample file ToBackend.dat from the folder ${XESProfileConfig}/configuration/TestData to the folder ${XESWorkspace}/test-data/1 Claim Intake.
  3. Go to the folder ${XESWorkspace}/test-data/ to view the processing results:
    • The directory ${XESWorkspace}/test-data/DeliveryToBackend/1. Backend Claim Format contains a DFF data.
    • The directory ${XESWorkspace}/test-data/Result contains a batch of 277 CA acknowledgements.
  4. If you have connected to Visualizer Server, open the Visualizer Server web interface and review the tracked items (transactions, claims, and acknowledgements) in the tracking pane.
  5. If you have connected to Visualizer Server, go to Visulazer Kibana and launch the HIPAA 837, 005010X222A1 dashboard. Claim-related information is displayed on the charts.

Test 2: Web Service Backend

The target adjudication system is SOA-based.

  1. Start the profile. Verify that all the required routes have been started.
  2. Copy the sample file ToWebService.dat from the folder ${XESProfileConfig}/configuration/TestData to the folder ${XESWorkspace}/test-data/1 Claim Intake.
  3. Go to the folder ${XESWorkspace}/test-data/ to view the processing results:
    • The directory ${XESWorkspace}/test-data/DeliveryToBackend/1. To Web Service System contains an XData file.
    • The directory ${XESWorkspace}/test-data/Result contains a batch of 277 CA acknowledgements.
  4. If Visualizer Server is plugged in, open the Visualizer Server web interface and review the tracked items (transactions, claims, acknowledgements) in the tracking pane.
  5. If you have connected to Visualizer Server, go to Visualizer Kibana and launch the dashboard HIPAA 837, 005010X222A1. The claim-related information is displayed on the charts.

Expected Results

Test 3: Undefined Backend

An undefined Backend is a scenario where the target adjudication system is not identified. Before you start on the steps below, remove the directories related to Test 1 and Test 2.

  1. Start the profile. Verify that all required routes have been started.
  2. Copy the sample file WrongSystem.dat from the folder ${XESProfileConfig}/configuration/TestData to the folder ${XESWorkspace}/test-data/1 Claim Intake.

Expected Results

  • The directory ${XESWorkspace}/test-data/DeliveryToBackend/1. Wrong Crosswalk Data has a 277 CA EDI file whose destination is not identified.
  • The directory ${XESWorkspace}/test-data/Result has a batch of 277 CA acknowledgements.
  • If you have connected to Visualizer Server, open the Visualizer Server web interface and review the tracked items (transactions, claims, and acknowledgements) in the tracking pane.
  • If you have connected to Visualizer Server, go to Visualizer Kibana and launch the HIPAA 837, 005010X222A1 dashboard. The claim-related information is displayed on the charts.