Business value in communication - IBM Websphere

A certain exchange of information occurs during each communication between a patient and a health care provider. In addition to the basics of patient demographics, symptoms, diagnoses, and treatments,a common Health Insurance Portability and Accountability Act (HIPAA) trading scenario requires the exchange of claims and payment data as well as associated payer,subscriber,eligibility, and authorization information. A single encountercan involve the transmission of large volumes of information among several participants.

The exchange of health care information can generally be viewed as a transaction between the sender and receiver participants.

Health care transactions include(but are not limited to):

  • Health care claim or encounter
  • Claim payment and remittance advice
  • Health care claim status
  • Coordination of benefits
  • Eligibility for a health plan
  • Referral certification and authorization
  • Enrollment and unenrollment in a health plan
  • Premium payments

this shows an example of a transaction that includes a health care claim and the claimpayment between two partners.

Health care claim processing

Health care claim processing

These transactions can be transmitted electronically in compliance with health care transaction standards. Health care data exchange standards allow the accurate and timely exchange of information between health care organizations.For example,a simple benefits inquiry can take 20 minutes on the phone. Using Electronic Data Interchange (EDI), his type of request can be processed almost immediately,without the need for a call to the insurers customer service center.

WebSphere Transformation Extender and its HIPAA EDI Pack provide predefined functionality that supports tactical HIPAA compliance, reduces the risks associated with complex compliance, provides standard-checking, cuts programming time and cost, and minimizes the need for back-end system reengineering.WebSphere DataPower B2B Appliance XB60 provides, at the network edge, B2B governance and high performance for full end-to-end processing with validation and functional acknowledgments,together with B2B Governance by enforcing Trading Partner Agreement policy and AS2/AS3 Standards compliance.

WTX with Launcher and WebSphere DataPower B2B Appliance XB60 provide a full end-to-end solution, covering all the requirements for a robust, scalable, and maintainable B2B infrastructure for partner trading. These requirements include:

  • The B2B document format must be HIPAA EDI X12 Version 5010.
  • All X12 data must be validated by the payer,and a functional acknowledgement must be returned with the validation status.
  • Data sent over the Internet must be signed and encrypted.
  • Data sent over the Internet must have a mechanism of verifying delivery of the message before closing the connection (sync acknowledgement).
  • The ability to view the status of transactions in the gateway must exist.
  • The ability to resend failed transactions from the gateway must exist.

Secure Sockets Layer (SSL) is not included in this scenario in the interest of brevity.


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