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