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X12 N834 Benefit Enrollment - Inbound

Updated on April 23, 2021

Pega Foundation for Healthcare provides a mechanism to manage membership enrollment workflow processes and be able to intake a HIPAA compliant 834 inbound messages for Member / Policy - Adds / Updates / Terminations.

Pega Foundation for Healthcare

The existing membership and policy workflows in the sample data admin portals will be enhanced and designed using data flows for each category of transaction:

  • New Benefit Enrollment Full File (typically generated monthly)
  • Benefit Enrollment Change File (for adds / updates / deletes of member and policy profiles)

The process work flows include the ability to pool cases for periodic batch file generation based on configurable time parameters (nightly / weekly / monthly) and a portal to manage and demo the transaction processing.

Business users are also able to model required transaction elements like transaction IDs, keys, and other metadata that is needed to generate HIPAA compliant outer loops of the transaction files.

The ability should include following:

  • Ability to ingest a change or monthly file
  • Ability to enroll a subscriber
  • A dashboard to run the sample demo
  • A configurable page to support mandatory elements configuration

Implemented the capability to read and Map Parsed-834 records from existing N834 table.

  1. A Job schedular – “Process834Records” implemented as part of PegaX12 application.
  2. This Job schedular is responsible for retrieving the persisted and unprocessed 834 records.
    1. Map the details to the existing PFHC Member -Policy Data modal.
    2. Create Enrollment case for each record with the data structure created above.

The following are the key features of Enrollment Case:

  • Stage-based case life cycle using the Pega Platform Case Designer to showcase the Enrollment Process.
  • Though There is no manual intervention in the case type at this point as we are creating the enrollment cases by reading 834 records, it is easy to extend and implement the manual process of Member -Policy Enrollment.
  • Create the Enrollment case as a parent case and child cases for each member/insurer in the select 834 record.
  • Enrollment case gets resolved once all the child cases gets resolved.
  • Implemented Exception handling and retry in case of exceptions as part of case life cycle.
  • Child case (member case) will be routed to the Admin WB in case of exception for further processing.

Customer can utilize these case types if their requirement matches or these case types can be extended and modify as per the requirement.

  • Previous topic Key rules for claims status request and response message
  • Next topic X12 N834 Benefit Enrollment - Outbound

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