Method and apparatus for integrating health care payers and provider systems with health care transaction systems using a single HIPAA EDI response generation component

• US 10,289,978 B2
• Filed: 08/04/2008
• Issued: 05/14/2019
• Est. Priority Date: 08/04/2008
• Status: Active Grant

• Current Assignee: Kyndryl Incorporated
• Original Assignee: International Business Machines Corporation
• Inventors: Lu, Anh Q., Pamu, Gautham, Yu, David Y.
• Primary Examiner(s): Sereboff, Neal
• Application Number:
  US12/185,178
• Publication Number:
  US 20100030599A1
• Time in Patent Office: 3,935 Days
• Field of Search: None
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes

Abstract

A method, system, and computer program product for integrating Health Care Payers and Providers with a health care transaction system. The health care transaction (HCT) utility solves the problem of integration between these two parties by providing the developer with an application that is capable of automatically generating an Electronic Data Interchange (EDI) response message to a request. The HCT utility mainly consists of a servlet (associated with the Hypertext Transfer Protocol (HTTP) or other data communication protocol) that forwards an EDI request from a sending party to applications that may act as either a payer or provider. These applications may automatically process and respond to request EDI messages sent from other applications using an EDI processor application. The HCT utility provides the advantage of providing an infrastructure for testing healthcare transactions. Furthermore, the infrastructure enables testing of a variety of transactions from multiple sources. Additionally, clearinghouse testing may now be automated.

Claims

1. In a data processing system, a method comprising:

integrating software endpoint applications with a single transaction facility to enable transactions between a first endpoint and a second endpoint, wherein the first endpoint and the second endpoint are respectively represented by a service provider computer and a service payer computer, and wherein said integrating supports integrating operations of the service provider computer and the service payer computer in the data processing system;

providing a testing facility to enable a test of a variety of transactions;

automating a clearinghouse test procedure via the testing facility;

providing an application plug-in facility to enable a simultaneous testing of multiple Electronic Data Interchange (EDI) exchanges;

receiving an EDI request message from the first endpoint;

generating an EDI response message in response to the EDI request message; and

in response to the EDI response message being generated, transmitting the EDI response message to the first endpoint.

2. The method of claim 1, wherein said generating comprises:

filling in response fields with the values related to data in the request or data from the database;

creating one or more of an Industry Standard Architecture (ISA) header and Transaction Set Header (ST) segments;

constructing, using with one or more of the ISA header and the ST segments, a placeholder representing a body of the response message; and

developing a set of loops and a group of segments to contain the response message.

3. The method of claim 1, comprising:

collecting data for a data pool from subscriber data exported from a payer system or subscriber data created by the testing facility;

constructing metadata with data from a data pool;

building a set of test cases using the metadata, wherein said metadata has an xml file format;

obtaining a test case metadata from the data store;

building a test request message based on the metadata;

evaluating a payer facility with an aid of the test provider facility;

sending test request messages synchronously to the payer system;

logging request information in the data store;

building an expected response for the test request message;

identifying a response for a corresponding request using an Industry Standard Architecture (ISA) correlation ID in the request message;

validating sections of the responses based on a comparison with the expected response; and

publishing the results to the data store after comparing the messages.

4. The method of claim 1, comprising:

in response to a receipt of the response corresponding to the request, updating the status of the test results in the data store;

obtaining metadata for the test case by one or more of (a) random selection from a pool of values in a database and (b) reuse of an existing test case data;

generating the request based on the type of request that is denoted in the test case, and utilizing the data and the test case metadata;

when a current selection of metadata is not obtained from the reuse of an existing test case data, saving the current selection of metadata as a rule based case or a static test case, wherein said rule based case enables a random selection of data from a pool based on one or more data selection options;

in response to a random selection of metadata, generating a response message with a random message type, wherein a random request is generated from one or more of (a) a selection of values from a database or (b) reuse of an existing rule based test case;

in response to EDI response message generation, wrapping the EDI message with Industry Standard Architecture (ISA) headers to send off to the external Payer;

monitoring for receipt of a response to the transmitted message;

comparing the response with one of a static pre-selected response or a dynamic response generated from the request, wherein a result of a comparison of the response is focused on selected values in EDI segments;

when the service payer computer or a computer which receives the response does not provide an acknowledgment reply, concluding the testing process without receipt of the acknowledgment reply; and

upon completion of the service payer computer testing, updating the database with the test case results.

5. The method of claim 1, comprising:

configuring a payer test facility;

initiating an evaluation of the service provider computer utilizing the test payer facility;

after said receiving the EDI request message, logging the EDI request message;

reading values from EDI segments inside the request message;

creating basic EDI Segments for a response message;

dynamically creating values based on Health Insurance Portability &

Accountability Act (HIPAA) transaction guidelines and payer options;

constructing the response message with a subset of the values;

in response to a successful creation of the basic EDI segments, wrapping the EDI segments with an Industry Standard Architecture (ISA) header;

sending the response message having one or more wrapped EDI segments;

determining whether the external provider accepts the generated EDI response message based on a request for a functional acknowledgment message, wherein said acknowledgment message provides information about the presence of semantic errors in the transmitted response message; and

in response to the service provider computer which receives the response not providing an option to provide the acknowledgment message, concluding the testing process without receipt of the acknowledgment message reply.

6. The method of claim 1, comprising:

providing an administration console facility;

providing a login facility to control at least one of (a) access to features and (b) initiation of tasks within an administration console;

in response to completion of a successful login, enabling access to console features and execution of tasks within the administration console;

configuring a set of database connections;

creating one or more test payer facilities and one or more test provider facilities;

initiating a configuration of a first set of properties of a test payer facility and a second set of properties of a test provider facility, wherein the configuration is initiated via a web browser interface;

selecting a type of plug-in application to use;

in response to a selection of a plug-in application, enabling a management of test cases or transaction endpoints via a test case manager, wherein said test case manager enables one or more of;

creation of a test case;

modification of the test case;

deletion of the test case;

execution of the test case; and

identification of a status of the test case;

during the creation or the modification of the test case, enabling an association of transaction endpoints with the test case, wherein said endpoints are associated with one or more of (a) internal applications useful to an integration of a facility and (b) external applications useful to an integration;

specifying, via a facility that manages transaction endpoints, details of endpoints for use in various test cases; and

during the integration of HealthCare Payers and Providers facility, creating a facility for test cases that operates as one or more of;

an internal payer;

an internal provider;

a reference external payer; and

a reference external provider.

7. The method of claim 1, wherein the data processing system comprises an apparatus, wherein the apparatus comprises a processor and a read-only memory (ROM) hard-wired into the apparatus, said ROM containing program code, which upon being executed by the processor, implements the method, and wherein the apparatus is a special purpose machine specific to the method due to the ROM being hard wired into the apparatus.

8. The method of claim 1, further comprising:

requesting a Functional Acknowledgement Message (FAM) from the service provider computer; and

determining from the FAM message received from the service provider computer that the EDI response is valid.

9. A computer program product, comprising:

a non-transitory computer readable storage medium; and

program code on said computer readable storage medium that when executed within a data communication device generating application data, said program code being for;

integrating software endpoint applications with a single transaction facility to enable transactions between a first endpoint and a second endpoint, wherein the first endpoint and the second endpoint are respectively represented by a service provider computer and a service payer computer, and wherein said integrating supports integrating operations of the service provider computer and the service payer computer in a data processing system;

providing a testing facility to enable a test of a variety of transactions;

automating a clearinghouse test procedure via the testing facility;

providing an application plug-in facility to enable a simultaneous testing of multiple Electronic Data Interchange (EDI) exchanges;

receiving an EDI request message from the first endpoint;

generating an EDI response message in response to the EDI request message; and

in response to the EDI response message being generated, transmitting the EDI response message to the first endpoint.

10. The computer program product of claim 9, wherein said program code for generating comprises program code for:

filling in response fields with the values related to data in the request or data from the database;

creating one or more of a Industry Standard Architecture (ISA) header and Transaction Set Header (ST) segments;

constructing, using with one or more of the ISA header and the ST segments, a placeholder representing a body of the response message; and

developing a set of loops and a group of segments to contain the response message.

11. The computer program product of claim 9, wherein said program code comprises program code for:

collecting data for a data pool from subscriber data exported from a payer system or subscriber data created by the testing facility;

constructing metadata with data from a data pool;

building a set of test cases using the metadata, wherein said metadata has an xml file format;

obtaining a test case metadata from the data store;

building a test request message based on the metadata;

evaluating a payer facility with an aid of the test provider facility;

sending test request messages synchronously to the payer system;

logging request information in the data store;

building an expected response for the test request message;

identifying a response for a corresponding request using the Industry Standard Architecture (ISA) correlation ID in the request message;

validating sections of the responses based on a comparison with the expected response; and

publishing the results to the data store after comparing the messages.

12. The computer program product of claim 9, wherein said program code comprises program code for:

in response to a receipt of the response corresponding to the request, updating the status of the test results in the data store;

obtaining metadata for the test case by one or more of (a) random selection from a pool of values in a database and (b) reuse of an existing test case data;

generating the request based on the type of request that is denoted in the test case, and utilizing the data and the test case metadata;

when a current selection of metadata is not obtained from the reuse of an existing test case data, saving the current selection of metadata as a rule based case or a static test case, wherein said rule based case enables a random selection of data from a pool based on one or more data selection options;

in response to a random selection of metadata, generating a response message with a random message type, wherein a random request is generated from one or more of (a) a selection of values from a database or (b) reuse of an existing rule based test case;

in response to EDI response message generation, wrapping the EDI message with Industry Standard Architecture (ISA) headers to send off to the external Payer;

monitoring for receipt of a response to the transmitted message;

comparing the response with one of a static pre-selected response or a dynamic response generated from the request, wherein a result of a comparison of the response is focused on selected values in EDI segments;

when the service payer computer or a computer which receives the response does not provide an acknowledgment reply, concluding the testing process without receipt of the acknowledgment reply; and

upon completion of the service payer computer testing, updating the database with the test case results.

13. The computer program product of claim 9, wherein said program code comprises program code for:

configuring a payer test facility;

initiating an evaluation of the service provider computer utilizing the test payer facility;

after said receiving the EDI request message, logging the EDI request message;

reading the values from EDI segments inside the request message;

creating basic EDI Segments for a response message;

dynamically creating the values based on Health Insurance Portability &

Accountability Act (HIPAA) transaction guidelines and payer options;

constructing the response message with a subset of the values;

in response to a successful creation of the basic EDI segments, wrapping the EDI segments with an Industry Standard Architecture (ISA) header;

sending the response message having one or more wrapped EDI segments;

determining whether the external provider accepts the generated EDI response message based on a request for a functional acknowledgment message, wherein said acknowledgment message provides information about the presence of semantic errors in the transmitted response message; and

in response to the service provider computer which receives the response not providing an option to provide the acknowledgment message, concluding the testing process without receipt of the acknowledgment message reply.

14. The computer program product of claim 9, wherein said program code comprises program code for:

providing an administration console facility;

providing a login facility to control at least one of (a) access to features and (b) initiation of tasks within an administration console;

in response to completion of a successful login, enabling access to console features and execution of tasks within the administration console;

configuring a set of database connections;

creating one or more test payer facilities and one or more test provider facilities;

initiating a configuration of a first set of properties of a test payer facility and a second set of properties of a test provider facility, wherein the configuration is initiated via a web browser interface;

selecting a type of plug-in application to use;

in response to a selection of a plug-in application, enabling a management of test cases or transaction endpoints via a test case manager, wherein said test case manager enables one or more of;

creation of a test case;

modification of the test case;

deletion of the test case;

execution of the test case; and

identification of a status of the test case;

during the creation or the modification of the test case, enabling an association of transaction endpoints with the test case, wherein said endpoints are associated with one or more of (a) internal applications useful to an integration of a facility and (b) external applications useful to an integration;

specifying, via a facility that manages transaction endpoints, details of endpoints for use in various test cases; and

during the integration of HealthCare Payers and Providers facility, creating a facility for test cases that operates as one or more of;

an internal payer;

an internal provider;

a reference external payer; and

a reference external provider.

15. The computer program product of claim 9, wherein the data communication device comprises the storage medium, wherein the storage medium comprises a read-only memory (ROM) hard-wired into the data communication device, wherein the ROM contains the program code, and wherein the apparatus is a special purpose machine specific to the program code due to the ROM being hard wired into the data communication device.

16. The method of claim 9, comprising program code for:

after said transmitting the EDI response message, requesting a Functional Acknowledgement Message (FAM) from the service provider computer; and

determining from the FAM message received from the service provider computer that the EDI response is valid.

17. A data processing system, comprising:

a processor executing a servlet application;

a memory system;

a network mechanism that enables connecting of data processing systems;

a utility which when executed in said data processing system provides functions for;

integrating software endpoint applications with a single transaction facility to enable transactions between a first endpoint and a second endpoint, wherein the first endpoint and the second endpoint are respectively represented by a service provider computer and a service payer computer, and wherein said integrating supports integrating operations of the service provider computer and the service payer computer in the data processing system;

providing a testing facility to enable a test of a variety of transactions;

means for automating a clearinghouse test procedure via the testing facility;

providing an application plug-in facility to enable a simultaneous testing of multiple Electronic Data Interchange (EDI) exchanges;

receiving an EDI request message from the first endpoint;

generating an EDI response message in response to the EDI request message; and

in response to the EDI response message being generated, transmitting the EDI response message to the first endpoint.

18. The data processing system of claim 17, wherein said functions for generating comprises functions for:

filling in response fields with the values related to data in the request or data from the database;

creating one or more of a Industry Standard Architecture (ISA) header and Transaction Set Header (ST) segments;

constructing, using with one or more of the ISA header and the ST segments, a placeholder representing a body of the response message; and

developing a set of loops and a group of segments to contain the response message.

19. The data processing system of claim 17, wherein said utility comprises functions for:

collecting data for a data pool from subscriber data exported from a payer system or subscriber data created by the testing facility;

constructing metadata with data from a data pool;

building a set of test cases using the metadata, wherein said metadata has an xml file format;

obtaining a test case metadata from the data store;

building a test request message based on the metadata;

evaluating a payer facility with an aid of the test provider facility;

sending test request messages synchronously to the payer system;

logging request information in the data store;

building an expected response for the test request message;

identifying a response for a corresponding request using the ISA correlation ID in the request message;

validating sections of the responses based on a comparison with the expected response; and

publishing the results to the data store after comparing the messages.

20. The data processing system of claim 17, wherein the data processing system comprises an apparatus, wherein the apparatus comprises the processor and the memory system, wherein the memory system comprises a read-only memory (ROM) hard-wired into the apparatus, wherein the ROM contains program code for implementing the functions provided by the utility, and wherein the apparatus is a special purpose machine specific to the functions provided by the utility due to the ROM being hard wired into the apparatus.