The Enterprise Data Services team, led by Rama Kakarala, is responsible for ingesting data into Horizon's data storage platforms and enabling business users to report on and send data to external vendors and partners.

Facing a tight deadline to meet new interoperability standards for healthcare payers introduced in 2020, Horizon needed to rework their data ingestion framework to support the Fast Healthcare Interoperability Resources (FHIR) EDI file format – and quickly. Rama and his team turned to CData ArcESB to quickly spin up a solution to map and ingest EDI documents received from external partners and translate the data to create FHIR-compliant documents.

The Challenge: Supporting EDI to Comply with New Industry Mandates

Horizon Blue Cross Blue Shield of New Jersey batch processes multiple types of data, including internal enrollment data, as well as claims and encounter data from external healthcare providers. Horizon's ingestion framework, built on top of Apache Spark, was previously engineered to receive data in JSON or CSV formats. However, new mandates have challenged Horizon to receive and process EDI files to meet FHIR format standards.

“In this industry now, we are obligated to meet this new interoperability mandate," said Rama Kakarala, Horizon Data Services Manager. “So when we get this new encounter data from our partners like LabCorp and HearUSA, that is coming in the EDI format. We need to process that data and create an EOB (Explanation of Benefits) document by integrating with internal data in a CSV format, then send it to our interoperability partner."

But Horizon did not have an in-house expert to help map and implement this new data transformation process.

“We had a technical gap that we needed to close," said Rama. “The EDI 837 file format is very complex, so very few SMEs across the company can understand the entire EDI layout. That's why we were looking for a tool that could easily do the job of mapping the EDI file and converting it into a format we can use."

“We had a technical gap that we needed to close. The EDI 837 file format is very complex, so very few SMEs across the company can understand the entire EDI layout. That's why we were looking for a tool that could easily do the job."

– Rama Kakarala, Horizon Blue Cross Blue Shield of New Jersey Data Services Manager

The Solution: Expert EDI Mapping and Integration

Horizon chose CData ArcESB as their EDI provider based on carefully laid out criteria, including a need for automated ingestion and file translation, out-of-the-box connectivity, and intelligent communications features.

In just under six weeks, Horizon was able to work with the ArcESB team to carefully map out their needs and implement a compliant EDI solution. The tool allowed them to receive EDI 837 files from partners, translate and integrate the data with their internal CSV files to automatically create an EOB, and send the newly formatted FHIR document to their external interoperability partner.

ArcESB is a simple, yet powerful drag-and-drop integration solution that allows organizations to automate EDI processes quickly and easily. Drummond-Certified, the tool is built to support every major EDI standard, document, and protocol, and meet every stringent industry requirement for data transformation.

“Our enterprise architects evaluated multiple products and we conducted a POC (proof of concept) with CData ArcESB to see if it fit our needs," said Rama. “Based on our success criteria, the choice was clear."

“Our enterprise architects evaluated multiple products and we conducted a POC with CData ArcESB to see if it fit our needs. Based on our success criteria, the choice was clear."

– Rama Kakarala, Horizon BCBS Data Services Manager

Horizon also leveraged ArcESB's automated error logging and communications features to maintain the integrity of their data through the transformation process.

Rama's team plans to leverage ArcESB's powerful business rules to ensure data quality remains uncompromised. Each time a record is rejected or discarded, ArcESB will generate an error message for the team to inspect, triage, and report on. If the data is rejected for any reason, ArcESB will automatically generate an error message and send a communication to an email distribution list.

In the future, Horizon Blue Cross Blue Shield of New Jersey also has plans to integrate their CData ArcESB solution with their data lake. This process will automatically write all data errors and other quality metrics to their data lake, allowing the Data Strategy and Governance team at Horizon to access the data, understand how the organization is using it, monitor the time it takes to ingest and transform it, and generate actionable reports.