Download - QNXT Integration - Final
Connecting QNXT Reports and Interfaces
AAJ Technologies
Thursday, April 09, 2015
Introduction
Babar ShahzadMCTS - BizTalk®, MCTS - .Net Framework, MCSD Senior Consultant – Systems Integration
10 plus years experience of working in IT Software development projects. Core specialty is in Systems Integration.
Extensive knowledge about technical functionalities and architecture for fast growing sectors like Healthcare, Banking, Government, Independent Software Vendors.
• Why Extract/Load Data in QNXT
• Kind of reports/interfaces
• Different types of Input types EDI, Flat File, XML and challenges associated with different data types
• Ideal architecture
• How to extract/load data in QNXT
• Some valuable reports/interfaces
Agenda
• QNXT™ is a name and trade mark of product developed by TriZetto
• An administrative system that supports medical and dental claims processing
• Developed using Microsoft technologies with service-oriented architecture
• A configurable and rule driven system
Quick Review - What is QNXT ?
QNXT Implementation in an Enterprise
QNXT(Hosted)
Banks
Fulfillment TP
Trading Partner 2
Trading Partner 1
QNXT (Local)
Legacy Providers Mgmt. System
AHCA/State
Reporting System
Client
Care Mgmt. System
Trading Partner 2
Trading Partner 3
Trading Partner 1
QXI
QNXT Application
Encounters
Trading Partner 3
Data Sync.
Postive Pay
Explanation of Payment (EOP)
ID Cards
Member Letters
Denial Letters
Checks
Provider Letters
837837
ProvidersProviders
Claims Data837 Encounter
Mass Providers Registration
Reports
Authorization
834
834 834834
837
Data
Reports Data
Reports Data
Reports
Why Extract/Load Data in QNXT
• Integrate with internal and external systems
• Develop Custom Reports
• Customize the Product
• Automate business processes
• Support enterprise workflows
Kind of Reports/Interfaces
• Enterprise
• Trading Partners
• State/Compliance
Different types of Input/Output types
QNXT(Hosted)
Banks
Fulfillment TP
Trading Partner 2Trading Partner 1
QNXT (Local)
Legacy Providers Mgmt. System
AHCA/State
Reporting System
Client
Care Mgmt. System
Trading Partner 2 Trading Partner 3Trading Partner 1
QXI
QNXT Application
Encounters
Trading Partner 3
RAW/SQL (Data)
Fixed Length Flat File (Postive Pay)
Flat File (EOP)
| Delimited Flat File (ID Cards)
Flat File (Member Letters)
Flat File (Denial Letters)
Flat File (Checks)
Flat File (Provider Letters)
EDI (837)EDI (837)
XML (Providers List)Providers
Raw Data, SQL (Claims)EDI (837 Encounter)
Fixed Length Flat File (Mass Providers Registration)
Excel, PDF, HTML (Reports)
SOAP Request/Response( Authorization)
EDI (834)
EDI (834) EDI (834)EDI (834)
EDI (837)
Raw/SQL (Data)
RAW/SQL (Reports Data)
Excel, PDF, HTML (Reports)
Challenges
• Data Validation
• Consolidation/Enrichment
• Interoperability
• Monitoring and Tracking
Ideal Architecture
• Loosely Coupled
• Easy to Develop/Enhance/Maintain
• Scalable/Reliable
• Secure
Ideal Architecture
• <Diagram>
Extract/Load Data in QNXT
• Direct DB Access• Production Database• Local/ODS
• Web Services (QXI)• SOAP
• Import/Export• EDI• Flat File
Interfaces
Direct DB Access (Encounter Process)
Extraction
Enrichment
Scrubbing
Validation
QNXT
Care Mgmt. System
Trading Partner
State
Internal Business
Users
Systems ClientsClaims Data Extraction and
Validation
Fixation
837 File Creation
File Validation
File Delivery
835 Response update
Claim Reports
File Generation
Encounters
Using QXI (Authorizations)
Extraction
QNXT
Client 1
Client 2
Internal Business
Users
Systems ClientsMembers Authorization
Authorization File Creation
Checksum FileGeneration
File Delivery
Archiving
File Generation
Conversion and Validation Reports
Authorizations Creation and Management
QXI
Import/Export - Membership Enrollment and Maintenance
Care Management System
Extraction
Enrichment
Scrubbing
Validation
Trading Partner 1
Internal Business
Users
Systems Clients/SystemsData Extraction & Preparation
File Creation
File Validation
File Delivery
Reports
File Generation
Trading Partner 2
QNXT
Import/Export (Automatic Membership Assignment)
Member EnrollmentEnroll Member
Assign PCP
Assign GEO location
Assign PCP
Files Delivery
FTP/SFTPFile Generation
QNXT Application
834 EDI file
Monthly Magic Process
Update PCP Assignment
Validation and Logging
QNXT
Validate PCP Assignment
FTP
Reports
• Enterprise Reports• State Reports
Types of Reports
• To Support Decision Making• KPIs• Dash Board
• To Support Operation Needs• Ad-hoc• Functional Areas• Members• Claims• Finance• Provider Management• Encounters• Compliance
Enterprise Reports
Enterprise Reports - Examples
Name Related ToNew Enrollments MemberDisenrollment MemberActive Members MemberCensus MemberCase Manager Encounter Case ManagerCase Manager Distribution Case ManagerProvider Utilization Provider ManagementProvider Data feed error Provider ManagementPaid Claims Summary ClaimCare Plan Approval Status Care PlanService Authorization Service AuthorizationCall Register VendorVendor List Vendor
• State Mandated• Template driven by state• Timely Submission• Strict Naming Convention• Delivery to Compliance for Validation• Financial Penalties
State Reports
State Reports - Examples
Name Related ToClaims Aging Report & Optional Supplemental Filing Report ClaimEnrollee Complaints, Grievances and Appeals Report MemberProvider Complaint Report ProviderProvider Termination and New Provider Notification Report ProviderCase Manager Caseload Report Case ManagerDenial, Reduction, Termination or Suspension of Services Report MemberEnrollee Roster and Facility Residence Report MemberService Utilization Report MemberUnable to Locate/Contact Enrollee Report Member….….….
ABC201410KA130139
• Managed Care Plan’s three-character identifier = ABC• Four-digit year in which report is due = 2014• Two-digit month in which report is due = 10• One-character identifier for the report’s year type from the
Report Year Type Table = K• One-character identifier for report frequency from the Frequency
Code Table = A• Two digits indicating the specific data period being reported from
the Frequency Code Table (Reporting Data Period) = 13 (Reporting Data Period 2013)• Four-digit report code identifier for the Patient Responsibility
Report = 0139
State Reports
Reports Distribution Mechanism
Network Folder
SSRS Scheduler SSRS Subscription Reports Database
DBA
Users
Define/ModifyScheduler
Define/ModifySubscription
Reports Portal
QNXT
Reporting Services (SSRS)
Members (rdls)
Claims (rdls)
Providers (rdls)
Vendor (rdls)
Care Mgmt. System
Legacy Care Mgmt. System
Legacy Provider Mgmt. System
Trading Partner
State
Internal Business
Users
Systems ClientsReports Hosting
Others (rdls)
Reporting Portal / Scheduled Jobs
Members (aspx pages/Subscription)
Claims(aspx pages/Subscription)
Providers(aspx pages/Subscription)
Vendor(aspx pages/Subscription)
Others(aspx pages/Subscription)
Reports Rendering
Tools / Technologies
Thanks