Overview

In this sample monitor model for a healthcare business process, you will learn how to develop and deploy a monitor model using WebSphere Business Monitor Development Toolkit V6.2 on either Rational Application Developer V7.5.1 or WebSphere Integration Developer V6.2. You will also be able to run the monitor model and view the results using a pre-built dashboard which you will import into Business Space powered by WebSphere.

The business process featured in this sample is benefits and eligibility submission process in healthcare. Below is a diagram that describes this business process.

There is a demand in the healthcare industry to provide a single point of entry (like information gateway, as you see EDI Gateway in the above diagram) in dealing with various types of Health Insurance Portability and Accountability Act(HIPAA) transactions and intelligently route them to relevant legacy back-end systems. As shown in above diagram, the HIPAA request is sent to EDI basic validation service for validation. If it is a valid request, the message will be unbundled by EDI Unbundling Basic Service to several HIPAA messages. For each message, it will be validated whether it is a HIPAA270 message. The policy information will be retrieved from HIPAA270 message and then back-end system builds HIPAA271 message. After bundling and validation, the HIPAA271 message is back to client through EDI Gateway. This use case provides a snapshot of information on an existing health insurance policy holder. This service returns fundamental data associated with the patients' benefit and eligibility status based on their insurance identification information such as an insurance id or a plan id. Eligibility determination is a standard administrative transaction. The provider requests eligibility determination via provider portal, call center, fax or via batch submission. The transaction can be submitted by providers in a variety of fashions, including real-time and batch.

Benefits and Eligibility (B&E) requests are submitted to a benefits and eligibility submission process which in turn are accepted and evaluated. Finally the process will provide the patient status and request status.

In this sample, you will be doing the following:

• Create a visual model to display Benefits and Eligibility transactions on a USA map.
• Create some key performance indicators (KPIs) to display submission status.
• Create alerts for too many rejected requests and too many inactive patients.
• Create pie charts to analyze rejected submissions based the reasons for rejection.
• Create a line chart for monthly report on rejected requests and the reasons for rejection.