Benefits Inquiry Solution with Azure Logic Apps

Business Application Integration Development case study

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Challenge

Founded in 2005, HealthSun is a local Medicare Managed Care Organization with administrative offices located in Coconut Grove, Florida. Serving more than 40,000 Medicare Advantage consumers in Miami-Dade and Broward counties through its network of 19 wholly owned primary care and specialty centers, HealthSun is one of the fastest-growing health plans in South Florida.

CMS Requirement Compliance: HealthSun needed to comply with a CMS requirement to implement a standardized benefits inquiry system, despite not working with external service providers, within a short timeframe.

Desire for Cloud Technologies: HealthSun aimed to utilize cloud technologies to minimize initial infrastructure investment and ensure the solution’s future manageability.

Scope of Work Complexity: The scope of work included creating a 270/271 interface compliant with CMS guidelines and CAQH Phase II rules for benefit inquiries. This involved implementing real-time and batch interfaces and ensuring the security of the Health Plan Identifier (HPI) through encrypted channels.

Requirement for a Standardized System: HealthSun’s operations predominantly relied on wholly owned care centers with direct access to internal underwriting systems. While effective for their current operations, this setup required alignment with CMS guidelines for a standardized benefits inquiry system, necessitating a new approach to meet regulatory requirements.

SOLUTIONS & APPROACH

Microsoft Logic Apps
Microsoft Azure App Services
  • Microsoft Azure Cloud Adoption: HazenTech and KGO Consulting recommended Microsoft Azure Cloud and its associated Platform as a Service (PaaS) offerings due to their alignment with the client’s budget, time-to-market requirements, and CMS compliance needs.
  • Interface Development: The solution provided both XML/Soap and MIME interfaces to trading partners using Azure App Services, with authentication performed using X.509 certificates and credentials.
  • Azure Logic Apps Implementation: Microsoft Logic Apps was selected as the primary engine for creating the interface, leveraging its built-in Trading Partner management and Electronic Data Interchange (EDI) capabilities.
  • Process Flow and Data Handling: HealthSun’s solution allowed health providers to send encrypted SOAP/MIME requests, which were authenticated and processed by Logic Apps. The benefit inquiry module retrieved benefits data from Azure SQL, synchronized nightly with on-premises systems, and transformed data into the required format before returning it via Azure App Services. This approach ensured full compliance with CMS requirements, implementation of CAQH Phase II rules, real-time interfaces on SOAP and MIME, secure communication via TLS encryption, and better business insight through real-time reporting.

Results

HealthSun Health Plans successfully met CMS compliance and improved operational performance:

  • On-Time Delivery: Completed the project two weeks ahead of CMS deadlines, meeting all regulatory and security requirements.
    Cost Efficiency: Reduced infrastructure and operational costs by 40% with Microsoft Azure’s PaaS model.
  • High Availability: Achieved 99.9% uptime after deployment, ensuring uninterrupted provider access.
  • Compliance & Security: Met 100% of CMS 270/271 and CAQH Phase II standards with secure SOAP/MIME data exchange.
  • Process Automation: Enabled real-time benefit inquiries and faster claims verification via Azure Logic Apps.
  • Data Insights: Provided advanced reporting dashboards, improving oversight and decision-making efficiency.

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All projects are protected by NDA and IPs.