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Improving EDI Systems for Mental Health Facilities with CareLogic Optimization

Qualifacts’ CareLogic software is tailored for mental health facilities, streamlining patient information management and automating medical billing processes. Despite prior organizational challenges and a lack of documentation, the platform has evolved with multiple tailored versions for various organizations. Our current project focuses on standardizing the Electronic Data Interchange (EDI) processes for transferring claims to insurance companies and automating file management to enhance efficiency. We aim to establish a cohesive library for EDI files, ensuring seamless updates across all CareLogic implementations.

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Improving EDI Systems for Mental Health Facilities with CareLogic Optimization

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  1. Qualifacts EDI Project Adam Davie Clark Bedsole Tim Jansen Robert Jones

  2. Qualifacts • Sell software to Mental Health Facilities • The software organizes patient information and stores it in a database • Automates the process of billing for medical services • Insurance companies

  3. Company History • Did not work due to bad organizational management • Entire company was overhauled • Many different versions of CareLogic were created that were customized for individual organizations • Versions were not documented • Communication between developers was poor

  4. CareLogic • Web-based application created by Qualifacts and used by the mental health services to organize patient claims • Claims are approved and sent to insurance companies • Creates batches of the files and uploads them to the payers’ site

  5. CareLogic File Format Example • Each field represents some data for forms/records • Different symbols represent text formatting • The formatting is used to generate printed documents • In this example: • ; characters represent tabs • + characters represent new line ;1744;;;John Doe;;3/27/78+1239.00;

  6. Current CareLogic System Structure • Changes to the format of one type of file do not propagate to the various sites using the CareLogic system • The various files and formats are not organized and labeled • The payers determine how their files are formatted and structured • Currently no standardized method of formatting

  7. Claim Engine • Runs overnight and finds billable claims based on the preset rules • Rules: • Preprocessing • Service – Type of service • Financial – What to bill, How much to bill, etc • Post-processing

  8. EDI • Electronic Data Interchange • The method by which information is exchanged between patients, mental health facilities, and insurance companies.

  9. PL/SQL • Procedural Language/Structured Query Language • Programming language designed by Oracle for use with their database systems • 4th Generation Programming Language • Qualifacts has created a library of functions in PL/SQL that automate the generation of HTML

  10. Project Requirements • Construct a library of files for the EDI • Automate the management of EDI files • Addition, deletion, and editing • Create a system that automatically propagates changes to the files in the library to all sites that have implemented CareLogic

  11. Main Contacts • Lyn Givens • Senior Vice President of Operations • Brad Bills

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