Paradigm: Supplemental Partner Framework

Use Case Overview

• Objective:

  • Receive individual health claim bills in JSON format from ADVA.

  • Create one EDI 837 outbound file.

  • Send the merged EDI 837 file to the supplemental partner.

  • Receive pricing from the supplemental partner in the HCP segment of the EDI 837 file.

  • Process the EDI 837 file with HCP Segment and create a JSON having multiple bills. This JSON got split into multiple individual JSON and sent back to ADVA.
    
    

2. High-Level Design Overview

A. ASB Consumer

• Functionality:

  • Read bill JSON from Azure Service Bus (ASB).

  • Store the bills in the solution database named supplementaldata.

B. MergeJSON Process

• Trigger:

  • A calendar event triggers this process.

• Process:

  • Pick all bills with the status "price received" based on partnerID and bill type.

  • Once bills got picked, it also update the status as "Bill Merged" for all the bills that are merged

  • Each partner has a different calendar event with respect to bill type, ensuring one merged file is created for each partnerID with a particular bill type (HCFA and UB).

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C. Outbound Process

• Process:

  • The outbound transaction picks the merged JSON to create an EDI 837 file and the Custom Flow got triggered through the API used in the Outbound data mapping that is storing file level information in the filequeue table and bill level information in the SUPPL_BILL_DETAIL table.

• Transmission:

  • The EDI 837 file is sent to the supplemental partner through LAN.

D. Inbound Process

• Reception:

  • The supplemental partner sends pricing for the bill in the HCP segment of the file.

• Conversion:

  • The inbound process picks the EDI 837 file and converts it into JSON. It also insert the file level information in the filequeue table for all the EDI file recieved with HCP Segment

E. Split JSON Process

• Process:

  • Intermediate JSON files are picked using a file event and got split into individual JSON, if the entry exists in the SUPPL_BILL_DETAIL table then we will update the price information and set the status as "Bill Returned" for that bill in the SUPPL_BILL_DETAIL table

• Split:

  • The JSON is split from that file and individual JSON files are sent to ADVA through ASB.