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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.
HealthSun mostly operates through wholly owned care centers, and so did not need a benefit inquiry system. The care centers had direct access to internal underwriting systems, negating any need for a standardized interface.
This need arose from the CMS requirement that all Health Insurance companies implement at standard benefits inquiry system, even if they were not working with any external service providers. CMS required this interface to be implemented within a short amount of time.
Scope of work included creating the 270/271 interface and making it compliant with CMS guide lines. We also needed to consider CAQH Phase II rules for benefit inquiries. These guidelines included implementation of a real-time as well as a batch interface and securing the HPI with use of encrypted channels. HealthSun also desired to utilize cloud technologies wherever possible to keep initial infrastructure investment to minimum and make the solution easily manageable in future.
In a close partnership between Hazentech and KGO Consulting multiple solutions were evaluated. The team proposed Microsoft Azure Cloud and its associated PaaS services as it perfectly fits the client budget, time to market and other constraints to meet CMS compliance requirements. Microsoft Logic Apps was chosen as the primary engine for creating the interface as it provides built in Trading Partner management and EDI capabilities.
The solution provided both XML/Soap and MIME interfaces to trading partners using Azure App Services. The authentication of trading partners was performed using X.509 certificates in addition to credentials.
Health Providers send 270 requests on encrypted SOAP/MIME interface. After authentication, the request is processed by Logic Apps. This process flow resolves the trading partner and performs a series of data validations. The request is then sent to benefit inquiry module which retrieves the benefits data from Azure SQL. The member benefits data is nightly synchronized from on-premises underwriting system. The benefit inquiry module transforms the retrieved data into Logic App required 271 format using XSLT. Logic App then converts it into EDI format using its EDI connector and returns to Azure App Services based interface layer.
Technical resources from Hazentech and KGO Consulting worked together and completed the implementation within HealthSun’s budget and CMS’s mandated deadline, with some time to spare. The solution is fully compliant with all the CMS 270/271 compliance guidelines. Although the requirement to fully adhere to all CAQH Phase II rules and to test it using a CAQH approved test vendor was dropped during the project, the solution still implemented most of these rules.
By utilizing Azure services for all the components, we were also able to keep both the initial investment recurring operational costs low.