TriZetto QNXT is a longstanding leader in EDI healthcare administration platforms, supporting many lines of business including Medicare and Medicaid. An important function of QNXT is its strength in claim pricing, member administration and billing management. However, the provided QNXT toolset lacks flexibility in adapting to new processing requirements. For example, it would be difficult to perform member lookup and replacement prior to processing through QNXT’s modules.
Understanding the Workflow
QNXT utilizes Microsoft BizTalk Server to intake 837 claims files and EDI 834 enrollment files that are utilized in its various modules. The files are translated from EDI to XML within BizTalk’s native EDI parsing pipeline component deployed as part of QNXT’s ‘QNXT Connect’ BizTalk Application. The XML is then sent into QNXT where it travels through QNXT’s built-in agents and modules.
However, it is often the case that custom logic is necessary to ensure the success of the message within QNXT. This can be due to:
- Enrichments or lookups necessary to the file, such as the previously mentioned need for a member lookup and replacement
- Conditional routing based on success or failure of the file
- Pre-validation to prevent a single failed record from causing failure of the entire transaction set
Typical Solutions, and Their Limitations
Typically there are two ways to allow for the application of custom logic within a QNXT implementation – applications deployed in BizTalk, or custom agents deployed in QNXT.
Developing BizTalk applications, while very robust and flexible, require an advanced skill set to employ effectively. Not only does a developer have to know BizTalk, but also have a high degree of knowledge of XML in order to properly ‘work’ with the EDI. BizTalk does not supply out of the box APIs to ease the EDI development burden when working with healthcare data.
Looking back at the scenario of member lookups, a BizTalk application would have to be created that would perform member lookups and replacements. This however, would require knowledge of XPath navigation of the XML schemas used by BizTalk to update the member fields.
QNXT agents can be developed in C# .NET, and easily deployed using a QNXT provided deployment wizard. These agents can be positioned to execute prior to processing (Pre Agent) or post-processing (Post Agent). An executing agent has access to an XML representation of the EDI data received by QNXT, whether claims, enrollments or other data sets.
Using an agent negates the need for specialized BizTalk knowledge, however presents several limitations that have to be overcome:
- XML: EDI is presented as XML within another XML wrapper containing file specific metadata injected by Many layers of nesting and knowledge of XPath may present difficulty in developing an agent.
- Testing: Testing custom pre and post agents requires either attaching a debugger to QNXT or careful interpretation of log entries within the QNXT process log browser.
- Tracking: QNXT only surfaces the start and end of a custom agent’s execution, with only basic record counts and a success/failure logged.
- Maintenance: There is a wizard provided to deploy agents, however custom built agents may need frequent updates to ensure compatibility as new QNXT versions are deployed.
A Better Solution
EDI Software can be designed to integrate with your existing infrastructure. The T-Connect EDI Gateway offers a robust set of APIs, healthcare relational databases, workflow engine and management portal allowing for rapid implementation of complex workflows. T-Connect was built from the ground up focused on native X12 EDI support, allowing for parsing, EDI validation, splitting large EDI Files, and converting EDI to CMS 1500 form (PDF), along with many other features. Several implementation scenarios are supported, such as an in-place connector into BizTalk and QNXT.
With T-Connect’s workflow engine, the task of adding custom logic is effortless, presenting a simple interface to author routes composed of several steps. A step can receive, execute logic, and send the file to a destination. Logic executed can consist of out of the box steps or custom steps developed using the T-Connect step framework to inject any logic into the route. Pre-built steps included out of the box include:
- SNIP Validation and routing based on the validity of the file
- Persistence into T-Connect EDI Databases
- Splitting EDI files
- Data lookups and edits
- File renaming
Unlike QNXT Pre and Post agents, T-Connect custom steps have access to the full X12 EDI message, with full access to T-Connect’s robust EDI parser, validator, splitter and API tools. Upgrades and updates BizTalk or QNXT do not require changes to T-Connect, ensuring stability of the preprocessing workflow. Errors are surfaced directly within the T-Connect EDI Management portal, allowing seamless editing and resubmission of problem claims or enrollments.
Preprocessing EDI files is well within grasp when using our array of HIPAA EDI Solutions within your existing TriZetto QNXT implementation. Our expansive set of tools and wealth of industry expertise empower your team’s ownership of the EDI lifecycle.