5010 EDI 837 Claim Processing
$25,000,000.00 Healthcare Exchange project to modernize transaction processing

Overview
Using Service Oriented Architecture and Model Driven Architecture, we designed a new healthcare claim, enrollment and member management transaction processing engine for a large Insurance provider. This multi year, multi million dollar project was designed, developed and implemented from the ground up.

Project Characteristics

  • Several thousand providers submitting EDI transactions, claims and authorizations to the payer's portal
  • Real time Application to application, service to application, SFTP to file transforms designed and developed
  • Guaranteed delivery of transactions whether real time or batch
  • Full redundancy and highly available level 1 enterprise solutions
  • 24 x 7 x 365 support and maintenance

Architectural Artifacts

  • SOA Reference Architecture
  • Cross Domain, Federated Solution and Entrerprise Architecture Frameworks
  • Current State Solution Reference Architecture
  • Future State Cloud Solution Reference Architecture
  • BPM 2.0 APQC Level 3 Process Models
  • BPEL Deployable Composition Web Services
  • UML Use Cases
  • UML Deployment Model
  • UML Component Model
  • UML Class Metamodels
  • UML Sequence Models
  • Solution Security Reference Architecture
  • EDI Integration and Remediation Workflows
  • System Specifications
  • Business, Functional and Technical Requirements
  • Data Integration Architecture
  • Master Data Management
  • Federated Data Services

Project Statistics

  • 36 month Agile Scrum Implementation
  • 78 sprints/3 weeks each
  • 50 BizTalk, EDI, .NET and Java developers split into 10 functional teams
  • 3 onshore, 3 off shore teams
  • 15 testers
  • 50+ servers in production with full redundancy and offsite fail over
  • 75 story point velocity
  • Full Reporting and Big Data Analytics Solution delivered
  • Full support model and staffing remediation delivered

Technologies

  • Informatica Power Center
  • BPEL/BPMN 2.0 Real Time Process Composition Services
  • .NET 1.1-4.0
  • BizTalk 2012
  • Java
  • jQuery UI
  • Javascript
  • XML, XSD, XSLT
  • SOAPUi
  • LOADUi
  • Microsoft Test Manager
  • SQL 2012
  • IIS 7.5
  • MSMQ
  • EDI 837i, 837p, 837d, 835, 270, 271, 276, 277, 997, 999
  • Ansi X12
  • SOMF, SOAML
  • SCOM, SCCM, MS Operations Center
  • Tidal File Processing
  • Hyper-V
  • Sungard ECS and ECM