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Qualifacts EDI Project

Qualifacts EDI Project. Adam Davie Clark Bedsole Tim Jansen Robert Jones. Qualifacts. Sell software to Mental Health Facilities The software organizes patient information and stores it in a database Automates the process of billing for medical services Insurance companies.

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Qualifacts EDI Project

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  1. Qualifacts EDI Project Adam Davie Clark Bedsole Tim Jansen Robert Jones

  2. Qualifacts • Sell software to Mental Health Facilities • The software organizes patient information and stores it in a database • Automates the process of billing for medical services • Insurance companies

  3. Company History • Did not work due to bad organizational management • Entire company was overhauled • Many different versions of CareLogic were created that were customized for individual organizations • Versions were not documented • Communication between developers was poor

  4. CareLogic • Web-based application created by Qualifacts and used by the mental health services to organize patient claims • Claims are approved and sent to insurance companies • Creates batches of the files and uploads them to the payers’ site

  5. CareLogic File Format Example • Each field represents some data for forms/records • Different symbols represent text formatting • The formatting is used to generate printed documents • In this example: • ; characters represent tabs • + characters represent new line ;1744;;;John Doe;;3/27/78+1239.00;

  6. Current CareLogic System Structure • Changes to the format of one type of file do not propagate to the various sites using the CareLogic system • The various files and formats are not organized and labeled • The payers determine how their files are formatted and structured • Currently no standardized method of formatting

  7. Claim Engine • Runs overnight and finds billable claims based on the preset rules • Rules: • Preprocessing • Service – Type of service • Financial – What to bill, How much to bill, etc • Post-processing

  8. EDI • Electronic Data Interchange • The method by which information is exchanged between patients, mental health facilities, and insurance companies.

  9. PL/SQL • Procedural Language/Structured Query Language • Programming language designed by Oracle for use with their database systems • 4th Generation Programming Language • Qualifacts has created a library of functions in PL/SQL that automate the generation of HTML

  10. Project Requirements • Construct a library of files for the EDI • Automate the management of EDI files • Addition, deletion, and editing • Create a system that automatically propagates changes to the files in the library to all sites that have implemented CareLogic

  11. Main Contacts • Lyn Givens • Senior Vice President of Operations • Brad Bills

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