Medical Claims Processing Module That Transforms Files from HL7 to ANSI

About Our Client

The Client is a leading US-based provider of mobile X-ray, ultrasound, ECG, and bone density testing services.

Challenge

The Client turned to ScienceSoft’s health insurance software development team to create the concept of its new claims automation module. The module was intended to replace the third-party claim processing component that transforms HL7 claims received from the Client’s in-house enterprise management system into ANSI files for medical claims management software (clearinghouse). The Client’s principal requirement for a new internal module was to minimize the number of errors in claims sent to the clearinghouse software.

Solution

ScienceSoft’s consultants developed a concept of a module that will function as an intermediary between the Client’s enterprise management system and clearinghouse software and will not only replace the existing third-party solution but also significantly improve medical claim processing.

It was decided to introduce complex two-stage pre-processing so that the module could minimize the number of rejected claims and submit ‘clean’ ones that can pass all internal billing edits of the Client’s clearinghouse software on the first try. Comprising all coding formats in use (HCPCS/CPT, ICD, NPI, etc.) and multiple data components claims may include, the module will check, at the first stage, if a claim contains any errors and, at the following stage, if it provides all the data required for a standard form. Only after that the claim will undergo transformation into the ANSI format to be sent to the clearinghouse software.

As a whole, the module operates as follows:

• Receiving the messages from the enterprise management system in HL7 format.
• Reviewing potential claims.
• Transforming reviewed claims into ANSI files.
• Sending claims without errors on to the Client’s clearinghouse software.

Results

Serving as an intermediary between the Client’s enterprise management system and clearinghouse, the module will move the claim scrubbing process from the third party under the full control of the Client. Moreover, two stages of pre-ANSI review will reduce the frequency of errors in health claims transfered to the Client’s clearinghouse software, thus accelerating the e-billing process and letting the Client get its services timely paid.

Methodologies

Gap analysis, root cause analysis, process flow diagrams, value stream mapping.

Tools

Atlassian Jira, Atlassian Confluence, Bizagi Modeler, Mindjet Manager.