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Specialty Healthcare Benefits X12 EDI Workflow

Specialty Healthcare Benefits Manager Replaces Risky X12N EDI Integration Solution with PilotFish


A leading organization that provides health services was experiencing rapid growth and planning to double its size over the next five years. Enhancing its data integration solution was critical to meeting growth projections, improving efficiencies, and reducing any potential risks to its high-volume information processing capabilities. Integrating X12 EDI data with the organization’s diverse plans and programs posed a unique set of challenges that had to be met.

In this case study, discover how by leveraging PilotFish’s integration solution, with its specialized X12 EDI features, the organization benefitted from robust data integration and accurate validation and was able to achieve its goals.


THE CLIENT

The client, one of the nation’s largest health services organizations, has a large member base and offers a wide range of plans and programs. Growth was planned to be more than 100% over the next 5 years. To manage the new growth, it was expanding its technology leadership team. As part of this effort, the company gained a broader view of the options available in the marketplace to tackle both EDI integration and modernization.

THE CHALLENGE

The client’s data integration requirements are high volume and diverse. With their accelerated growth, the solution had to be both scalable and performant. In addition to handling X12 EDI data it needed to support other formats as well. Accurate and efficient validation was needed to eliminate risk and for faster processing.

New leadership had experienced PilotFish and other competitive products and determined that the PilotFish Integration suite with its depth of X12 EDI validation and overall performance was a good fit for the company’s needs. As part of the client’s evaluation process, which included taking advantage of PilotFish’s free 90-day trial, they directly compared PilotFish to other marketplace options. PilotFish proved to be superior in every aspect of data validation and integration.

THE SOLUTION

PilotFish delivered a comprehensive validation and data integration solution in one product. Introducing PilotFish delivered superior capacity for validation of X12 EDI and provided the organization with the functionality to transform and map EDI and any other data to or from any other application, system, or service using any communications protocol. The PilotFish solution proved flexible, scalable, and infinitely extensible.

PilotFish delivered specific built-in support for X12 EDI and offered comprehensive knowledge of X12 schemas and standards. These were huge time savers and provided substantial productivity gains.

PilotFish’s graphical 7-stage Automated Interface Assembly Line process and visual drag-and-drop Data Mapper allowed the client to utilize business analysts as part of the EDI team. The PilotFish process simplified building, managing, and maintaining interfaces. The most complex data mapping and data transformations were accomplished in minutes, with no coding or scripting required for the BAs.

PilotFish also supported SNIP Levels 1-7 for EDI transaction validation. PilotFish could validate SNIP Type 4 with a very robust set of semantic (situational) rules as defined in the X12 implementation guides. With SNIP Type 5, PilotFish validates against all external codes in the database, flags errors for remediation, and regularly updates and maintains codes. PilotFish also provided the ability to test every transaction sent or received to validate transaction compliance. This level of EDI validation was unique to PilotFish. 

Support for non-EDI formats presented no problem as well. PilotFish’s any-to-any data transformation capabilities and protocols supported all file-based integration scenarios. PilotFish easily handled client healthcare benefit and claims information in any format. Transformation modules also offered the ability to parse any format from any source.

THE BENEFITS

PilotFish provided the client with an easy interface maintenance and product replacement path. The PilotFish Assembly Line approach ensured that each interface was configured in the same way. Documentation was available in-line. Thus, dependencies were removed on who created an interface or how. 

PilotFish’s short learning curve was demonstrated early in the replacement process with an immediate reduction per integration cost with no loss of quality. PilotFish’s intuitive integration process and short learning curve enabled business analysts to quickly manage over 80-90% of configuration work. The teams across all areas needed to only learn and use one solution. 

PilotFish enabled multiple patterns for reuse, increasing efficiency and productivity. Cloning existing interfaces and tweaking them was easy. As usage grew, a library of existing templates to select for a new interface was built. Existing interfaces were also used as-is for multiple integration points, as was chaining “standard” interfaces with implementation-specific variants. PilotFish’s ease of reuse sped up integration while saving the firm money in the near term, with further savings projected.

PilotFish enabled faster processing. Transactions were seamlessly processed in both batch and real-time modes. While from a federal perspective, real-time response needs to be within 20 seconds, with PilotFish, real-time response was less than one second on average – a big gain.

With PilotFish, the company rapidly achieved benefits in the additional phases of the project to transform, modernize, and automate processes and workflows. Partnering with PilotFish helped the company achieve a lower total cost of ownership overall.

Since 2001, PilotFish’s sophisticated architecture and innovations have radically simplified how healthcare integration gets done. Today PilotFish offers the most flexibility and broadest support for healthcare integration of any product on the market and is system, platform and database agnostic. PilotFish’s healthcare integration suite includes support for all healthcare data formats (HL7 2.x, HL7 3.x, FHIR, CCD/CCDA, JSON, XML, X12 EDI, NCPDP, etc.) and communication protocols.

PilotFish is architected to be infinitely extensible with our Open API and flexible to meet any integration requirement. PilotFish distributes Product Licenses and delivers services directly to end users, solution providers and Value-Added Resellers. To learn more, visit our Case Studies or specific solutions like HL7 Integration or X12 EDI Integration.

PilotFish Healthcare Integration will reduce your upfront investment, deliver more value and generate a higher ROI. Give us a call at 813 864 8662 or click the button.

HL7 is the registered trademark of Health Level Seven International.
X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.

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