Blue Cross and Blue Shield of Massachusetts (BCBSMA), Inc. offers medical and dental plans, pharmacy coverage, vision coverage and health savings accounts. Founded in 1937, the company is ranked one of the top health plans in the nation, and is top rated for customer assessments, prevention and treatments.
Implementing healthcare reform measures impacts every aspect of operations for health plans like BCBSMA. Every system, interface or vendor application needed to be evaluated and adapted. The company needed a service-oriented design to support strategic goals through rapid composition of new applications allowing the business to rapidly adjust to federal mandates, participate in emerging Health Information Exchanges (HIE), and reuse business logic and data services across applications.
The solution consists of four main layers:
Business to Business (B2B) Gateway: Leveraging WebSphere ESB this layer provides standards based electronic data exchange capabilities. External partners securely submit EDI transactions and exchange information with a number of B2B channels supporting interactive and batch transactions.
EDI Transaction Processor: The platform leverages Edifecs XEngine to perform WEDI SNIP 1-5 validation, splitting, and acknowledgment generation, which validates incoming transactions against the appropriate specifications and performs edits according to business policies.
Services: The services layer exposes atomic and composite business services as required to support EDI transactions. The service operations expose a canonical model which is neither HIPAA version dependant or reliant on EDI structure, which allows services to support both 4010 and 5010 during the transition period and provides for reusability across other non-EDI applications within the enterprise.
Operational Data Store (ODS): Composed of Data Access services and a Healthcare Payer data model, the data store allows the services layer to source data from a single consistent source. Services then can be created at a business scope without having to understand how each back end system has organized its data.
Business Value Delivered
- Reduction of over $7 million in operation costs by enabling direct submission of transactions thereby eliminating the need for an EDI clearinghouse partner
- Significant reduction in maintenance costs through the replacement of a heterogeneous middleware with a standards-based WebSphere implementation
- Up to 300% increase in transaction processing capacity
- Improved business productivity due to increased operations visibility and system recovery capabilities