HIPAA Implementation at Highmark

Blue Vertex has spent two years assisting the EDI Services division of Highmark, an independent licensee of the Blue Cross Blue Shield Association, with the design and implementation of a world class enterprise solution for sending, receiving, and processing HIPAA compliant transactions.

The solution had to address the business requirements of Highmark’s unique and disparate legacy systems such as Electronic Claims Submission, Claims Adjudication, Integrated Customer Information, Membership, etc. It also needed to be virtually transparent to these legacy systems, while allowing Highmark to accept and deliver fully HIPAA compliant transactions. This was achieved through the use of third party Enterprise Application Integration / HIPAA transaction validation toolsets.

Project Highlights:

  • Implementation of the following HIPAA compliant transactions: 837 (Health Care Claims – I,P, & D), 834 (Benefit Enrollment & Maintenance), 270/271 (Health Care Eligibility/Benefit Inquiry and Information Response), 276/277 (Health Care Claim Status Request and Response), 278/278 (Health Care Services Request for Review and Response), 835 (Health Care Claim Payment), and 820 (Premium Payment)
  • Request / Response transactions were implemented to provide both batch and near real-time processing
  • In addition to integration with legacy systems, the solution had to support a robust reporting system
  • The solution was implemented using MQ Series and Oracle as an architectural backbone to ensure data integrity and delivery
  • Once the solution was implemented and production stable, it was then extended to support BlueExchange. BlueExchange is the enhanced version of the Blue Cross Blue Shield Association’s Interplan Teleprocessing Services (ITS). BlueExchange allows the carrier to route provider inquiries and link seamlessly to other insurance providers in its network, as well as to other insurance carriers, to send and receive HIPAA transactions. This allows consistency of information across all points of entry across all BCBSA member plans.

In addition, Blue Vertex assisted Highmark with database design, production support, problem resolution, and documentation.

Business Process Integration - Lincoln Financial Group

Blue Vertex worked with partner Metaserver along with IBM Global Services, McCamish Systems, and Seagull Software to deliver a real-time business process integration solution for Sales Authorization.

Blue Vertex contributed the following services to this successful implementation:

  • technical leadership
  • development expertise
  • software testing and problem resolution coordination
  • technical documentation preparation

The challenges we faced with this implementation included:

  • An extremely aggressive implementation schedule. Following a successful pilot phase, the solution was designed, developed, and tested in three months.
  • Complex business processes that combine in-house business rules and industry regulations, some of which are governed at the state level.
  • A large number of systems and technologies. Business processes involved four applications, on average, with several encompassing up to six disparate applications. Source applications exposed data and events in MS SQL Server. Target application environments included CICS and DB2.
  • System requirements including high availability, fault tolerance, and scalability to support real-time functionality.

Following the implementation, Blue Vertex continued to assist Metaserver and Lincoln with system tuning and several additional projects to expand support for new business areas.