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 20100030599A1
• Filed: 08/04/2008
• Published: 02/04/2010
• Est. Priority Date: 08/04/2008
• Status: Active Application

• Current Assignee: Kyndryl Incorporated
• Original Assignee: International Business Machines Corporation
• Inventors: Lu, Anh Q., Yu, David Y., Pamu, Gautham
• Granted Patent: US 10,289,978 B2
• Time in Patent Office: Days
• US Class Current: 705/7
• 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 at least one of a service provider facility and a service payer facility and said integrating supports operations of one or more payer facilities and one or more provider facilities;

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 EDI exchanges;

receiving a Electronic Data Interchange (EDI) request message from the first endpoint;

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

when the EDI response message is generated, transmitting the EDI response message to the first endpoint.

2. The method of claim 1, further comprising:

returning an acknowledgment EDI message to the sender when a response message for the received request is not generated; and

wherein when the EDI response message is generated, said generating further comprises;

retrieving a set of parameters including a patient'"'"'s subscriber identification (ID) and an eligibility status of the patient for a particular service; and

creating message component values useful to the response message from the set of parameters retrieved, wherein said message component values are retrieved from one or more of (a) data from within the request message and (b) data from within a database.

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

filling in response fields with the message component 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.

4. The method of claim 2, further comprising:

determining whether the request message is received from a transmitting provider facility or a transmitting payer facility;

forwarding the request message to a relevant EDI processor facility from within a set of EDI processor facilities via one of a receiving payer facility or a receiving provider facility;

wherein the receiving facility reads an identification (ID) of the corresponding transmitting facility;

wherein the payer facility contains a first set of EDI processor facilities and the provider facility contains a second set of EDI processor facilities;

wherein an EDI processor facility is implemented by an abstract processor class and the method further comprises extending the abstract processor class to implement the set of EDI processor facilities.

5. The method of claim 1, wherein said providing further comprises:

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

constructing meta-data with data from a data pool;

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

obtaining a test case meta data from the data store;

building a test request message based on the meta data;

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.

6. The method of claim 1, wherein said providing further comprises:

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 message component 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 meta data 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 meta data, generating a response message with a random message type, wherein a random requests is generated from one or more of (a) a selection of message component 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 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 message component values in EDI segments;

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

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

7. The method of claim 1, further comprising:

configuring a payer test facility;

initiating an evaluation of a provider facility utilizing the test payer facility;

receiving an EDI request message;

logging the request message;

reading message component values from EDI segments inside the request message;

creating basic EDI Segments for a response message;

dynamically creating message component values based on Health Insurance Portability &

Accountability Act (HIPAA) transaction guidelines and payer options;

constructing the response message with a subset of the message component values;

in response to a successful creation of the basic EDI segments, wrapping the EDI segments with an 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 acknowledgement message provides information about the presence of semantic errors in the transmitted response message; and

when the provider facility which receives the response does not provide an option to provide the acknowledgement message, concluding the testing process without receipt of the acknowledgement message reply.

8. The method of claim 1, further 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.

9. A computer program product comprising:

a computer readable medium; and

program code on said computer readable medium that when executed within a data communication device generating application data, said program code provides the functionality of;

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 at least one of a service provider facility and a service payer facility and said integrating supports operations of one or more payer facilities and one or more provider facilities;

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 EDI exchanges;

receiving a Electronic Data Interchange (EDI) request message from the first endpoint;

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

when the EDI response message is generated, transmitting the EDI response message to the first endpoint.

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

returning an acknowledgment EDI message to the sender when a response message for the received request is not generated; and

wherein when the EDI response message is generated, said generating further comprises;

retrieving a set of parameters including a patient'"'"'s subscriber identification (ID) and an eligibility status of the patient for a particular service; and

creating message component values useful to the response message from the set of parameters retrieved, wherein said message component values are retrieved from one or more of (a) data from within the request message and (b) data from within a database.

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

filling in response fields with the message component 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.

12. The computer program product of claim 10 further comprising program code for:

determining whether the request message is received from a transmitting provider facility or a transmitting payer facility;

forwarding the request message to a relevant EDI processor facility from within a set of EDI processor facilities via one of a receiving payer facility or a receiving provider facility;

wherein the receiving facility reads an identification (ID) of the corresponding transmitting facility;

wherein the payer facility contains a first set of EDI processor facilities and the provider facility contains a second set of EDI processor facilities;

wherein an EDI processor facility is implemented by an abstract processor class and the method further comprises extending the abstract processor class to implement the set of EDI processor facilities.

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

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

constructing meta-data with data from a data pool;

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

obtaining a test case meta data from the data store;

building a test request message based on the meta data;

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.

14. The computer program product of claim 9, wherein said program code for providing further 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 message component 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 meta data 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 meta data, generating a response message with a random message type, wherein a random requests is generated from one or more of (a) a selection of message component 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 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 message component values in EDI segments;

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

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

15. The computer program product of claim 9 further comprising program code for:

configuring a payer test facility;

initiating an evaluation of a provider facility utilizing the test payer facility;

receiving an EDI request message;

logging the request message;

reading message component values from EDI segments inside the request message;

creating basic EDI Segments for a response message;

dynamically creating message component values based on Health Insurance Portability &

Accountability Act (HIPAA) transaction guidelines and payer options;

constructing the response message with a subset of the message component values;

in response to a successful creation of the basic EDI segments, wrapping the EDI segments with an 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 acknowledgement message provides information about the presence of semantic errors in the transmitted response message; and

when the provider facility which receives the response does not provide an option to provide the acknowledgement message, concluding the testing process without receipt of the acknowledgement message reply.

16. The computer program product of claim 9 further comprising 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

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 at least one of a service provider facility and a service payer facility and said integrating supports operations of one or more payer facilities and one or more provider facilities;

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 EDI exchanges;

receiving a Electronic Data Interchange (EDI) request message from the first endpoint;

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

when the EDI response message is generated, transmitting the EDI response message to the first endpoint.

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

returning an acknowledgment EDI message to the sender when a response message for the received request is not generated; and

wherein when the EDI response message is generated, said generating further comprises;

retrieving a set of parameters including a patient'"'"'s subscriber identification (ID) and an eligibility status of the patient for a particular service; and

creating message component values useful to the response message from the set of parameters retrieved, wherein said message component values are retrieved from one or more of (a) data from within the request message and (b) data from within a database.

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

filling in response fields with the message component 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.

20. The data processing system of claim 18 said utility further comprising code that provides the functions for:

determining whether the request message is received from a transmitting provider facility or a transmitting payer facility;

forwarding the request message to a relevant EDI processor facility from within a set of EDI processor facilities via one of a receiving payer facility or a receiving provider facility;

wherein the receiving facility reads an identification (ID) of the corresponding transmitting facility;

wherein the payer facility contains a first set of EDI processor facilities and the provider facility contains a second set of EDI processor facilities;

wherein an EDI processor facility is implemented by an abstract processor class and the method further comprises extending the abstract processor class to implement the set of EDI processor facilities.

21. The data processing system of claim 17, wherein said functions for providing further comprises functions for:

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

constructing meta-data with data from a data pool;

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

obtaining a test case meta data from the data store;

building a test request message based on the meta data;

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.

22. The data processing system of claim 17, wherein said functions for providing further comprises functions 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 message component 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 meta data 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 meta data, generating a response message with a random message type, wherein a random requests is generated from one or more of (a) a selection of message component 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 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 message component values in EDI segments;

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

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

23. The data processing system of claim 17 said utility further comprising code that provides the functions for:

configuring a payer test facility;

initiating an evaluation of a provider facility utilizing the test payer facility;

receiving an EDI request message;

logging the request message;

reading message component values from EDI segments inside the request message;

creating basic EDI Segments for a response message;

dynamically creating message component values based on Health Insurance Portability &

Accountability Act (HIPAA) transaction guidelines and payer options;

constructing the response message with a subset of the message component values;

in response to a successful creation of the basic EDI segments, wrapping the EDI segments with an 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 acknowledgement message provides information about the presence of semantic errors in the transmitted response message; and

when the provider facility which receives the response does not provide an option to provide the acknowledgement message, concluding the testing process without receipt of the acknowledgement message reply.

24. The data processing system of claim 17 said utility further comprising code that provides the functions 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.