Case Study
Doctor
 

 
Eligibility determination system for Child and Adult Health Insurance Program
Client Government
Project Eligibility determination for Insurance Program
Executive Summary:
Children's Health Insurance Program and Adult Basic Health Insurance Programs are federally mandated programs that benefit permanent residents of United States of America. State government agencies are mandated by a federal ruling to implement this solution for the residents of each state, in partnership with companies providing health insurance coverage to residents. Aviana has designed, developed, deployed and continues to support a health insurance application that provide CHIP and Adult Basic Health Insurance Program for our client.
Developing a Child and Adult Health Insurance Program
Introduction
The core application platform used for this project was co-developed by Aviana for the client and its business partners:
The system comprises of a web-based interface for entering applicant information, accessible to each business partner and the client.
The web-based interface provides for application entry and application maintenance using industry standard technology and architecture, and provides for high availability and scalability.
The system also employs a "Batch Processing" component to determine eligibility of applications from potential participants in an offline mode during predefined batch processing schedules.
The batch processing schedule runs predetermined business rules; the business rules are configurable through a "Rules Engine".
The core of the system uses Internet based EDI to communicate with Business Partners using HIPAA. The solution employs a popular EDI & HIPAA tool from Microsoft, BizTalk Server 2002.
What Was The Problem?
The client did have an archaic Eligibility processing system that was:
Extremely difficult to use and master, the system was not intuitive, and had serious performance problems due to architecture and design flaws;
Required extensive maintenance programs increasing the TCO (Total Cost of Ownership) for the client.
The system was not robust and was not scalable beyond 50 users.
Why Aviana?
Aviana was tasked to design and implement this innovative system based on its well-recognized expertise in using Microsoft technologies for providing custom solutions to government agencies, as well as its functional knowledge of the insurance sector from prior engagements in the sector. In addition, Aviana had prior experience with the design and implementation of other such healthcare eligibility processing systems for many clients spread over several years.
Aviana's Solution
The redesigned and rearchitected system employed Microsoft DNA Technologies to provide the best possible ROI with minimal TCO. The redesign and rearchitecture was done with three main goals, near 100% reliability, near 100% availability with the best possible performance meeting Industry standards for security of enterprise systems deployed on the Internet.

The system architecture has four discrete tiers. Each tier addresses specific aspects of the system, and utilizes technologies designed to help realize the requirements assigned to each tier.
The Client Tier consists of HTML and Client scripting technologies to render the user interface.
The Presentation Tier is responsible for generating dynamic HTML content based on user interactions and business rules implemented using Microsoft ASP technologies using IIS 5.0 web server.
The Business Tier consists of COM+ components encapsulating Business logic and deployed in Microsoft COM+ runtime.
The Data Tier consists of an Industry standard Relational Database Management System (Oracle 8i).
The core of the system also includes the Batch and EDI modules. These modules were separated out of the online system to provide for linear and vertical scalability. Batch and EDI modules can be scaled out or scaled up without affecting online system and vice-versa.

The EDI functionality for the system uses Microsoft BizTalk Server 2002 -- a popular Industry tool to support EDI, along with Microsoft HIPAA accelerator for MS-BizTalk Server 2002. The EDI mechanism was designed to support EDINET an emerging Industry Standard for EDI over the Internet.