SUMMARY

BUSINESS PROBLEM

Any health plan that has substantive business operations will have a lot fo individual one on one contracts with Suppliers. These suppliers include Care Providers, Hospitals, Clinics, Doctors, and Pharmacies. There could be thousands of contracts. The contract definition is stored in a unique format in HealthRule called HealthRules Language or HRL, which HealthEdge's proprietary way of configuring business rules against which Claims get adjudicated. However, defining these contracts one by one in the HealthRules User Interface is not feasible. Hence, these contracts are generally defined in a spreadsheet. This creates the problem of converting those to HRL and ingesting into the HealthRules Engine. Traditionally, the loading of the contracts has been done by custom utilities and inserting converted HRL records directing into the database. The solutions have been one-offs and error-prone.

OVERALL APPROACH

SOLUTION

The solution entails a User Interface that is very easy to use and caters to a Business Analyst persona. Doing so ensures that a technical person is not needed. The core of the solution entails creating an HRL template and applying that towards a spreadsheet reliably. The application then orchestrates the HRL generation and insertions. It also allows for specific use cases for updating Supplier information as mass edits and updates. Proper user messages are shown on the UI, and the user gets meaningful reports and feedback. While my team prepared the design approach, I supervised the approach and directed the collaboration around the solution.

The follow snippets show the main contract generating and report screens.