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Case Study
Benefits Inquiry Solution with Azure Logic Apps
Industry: Healthcare
Solution: Application Development & Integration
The Client
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.
Business Challenge
HealthSun, a leading healthcare insurance company with a focus on wholly owned care centers, faced an unprecedented challenge when the Centers for Medicare & Medicaid Services (CMS) mandated the implementation of a standardized benefits inquiry system. Despite not relying on external service providers, HealthSun had to meet CMS guidelines within a tight timeframe. This case study showcases the effective solution that emerged, combining compliance with regulations, cloud technology utilization, and streamlined implementation for long-term manageability.
The primary objective for HealthSun was to create a compliant 270/271 interface that adhered to CMS guidelines for benefits inquiries. Simultaneously, the project aimed to align with CAQH Phase II rules, encompassing real-time and batch interfaces, secure HPI communication via encrypted channels, and cloud technology adoption to minimize upfront costs.
Tools & Technologies
- Microsoft Logic Apps
- Microsoft Azure App Services
- Microsoft Azure SQL Database
- Microsoft Azure Storage
- Microsoft SQL Server Integration Services
- Microsoft Team Services
- Microsoft .NET
- Entity Framework
- Oxygen XSLT / XML Editor
- Power BI
Realized Benefits
- Full compliance with CMS requirements
- Low capital investment and operational costs
- On-demand scalability
- CAQH Phase II rules implementation
- Real time interface on SOAP and MIME
- Batch interface via SFTP
- Secure communication via TLS encryption
- Out of the box tracking and monitoring
- Built in Trading Partners management in Logic App
- Better business insight with real time reporting
Solution & Approach
In close collaboration between HazenTech and KGO Consulting, multiple solutions were evaluated, ultimately leading to the selection of Microsoft Azure Cloud and its suite of Platform-as-a-Service (PaaS) offerings. Microsoft Logic Apps emerged as the ideal engine for developing the interface, leveraging its built-in Trading Partner management and EDI capabilities.
The solution facilitated XML/Soap and MIME interfaces for trading partners through Azure App Services, ensuring secure authentication using X.509 certificates and credentials. Health providers initiated encrypted SOAP/MIME-based 270 requests, which underwent a comprehensive process flow within Logic Apps. The requests were validated, processed by the benefit inquiry module, and retrieved member benefits data from Azure SQL. Synchronization of benefits data from the on-premises underwriting system occurred nightly. The benefit inquiry module transformed the data into 271 formats using XSLT, and Logic App seamlessly converted it into EDI format using the EDI connector. The result was then sent back to the Azure App Services-based interface layer.
Results
Through the combined expertise of HazenTech and KGO Consulting, the implementation of the benefits inquiry system was accomplished within HealthSun’s budget and the CMS-mandated deadline, with time to spare. The solution achieved full compliance with CMS 270/271 guidelines while incorporating a majority of the CAQH Phase II rules. By harnessing the power of Azure services, HealthSun minimized both initial investment and ongoing operational costs. Furthermore, the cloud-based approach offered scalability, simplified management, and real-time reporting capabilities, empowering HealthSun with invaluable business insights.
Conclusion
HealthSun’s journey to implement a standardized benefits inquiry system showcases the transformative power of cloud technology adoption, ensuring compliance with regulatory requirements and unlocking operational efficiencies. HazenTech and KGO Consulting’s collaborative efforts delivered a robust, scalable, and fully compliant solution that not only met CMS mandates but also offered enhanced business visibility. By embracing Microsoft Azure Cloud and Logic Apps, HealthSun is well-positioned for future growth, supported by seamless integration with trading partners, secure data transmission, and a future-proof interface.
