Solution Architecture Example: Nouveau Health …

1 Global Headquarters 3303 Hillview Avenue Palo Alto, CA 94304 Tel: +1 650-846-1000 Toll Free: 1 800-420-8450 Fax: +1 650-846-1005 2008, TIBCO Software Inc. All rights reserved. TIBCO, the TIBCO logo, The Power of Now, and TIBCO Software are trademarks or registered trademarks of TIBCO Software Inc. in the United States and/or other countries. All other product and company names and marks mentioned in this document are the property of their respective owners and are mentioned for identification purposes only. Solution Architecture example : Nouveau Health Care Claim Payment Solution Architecture This document presents an example Solution Architecture document. For brevity, some sections are intentionally left incomplete Document Document Title Here 2 Table of Contents 1 Business Objectives and Constraints .. 5 Quantified Business Expectations.

2 5 Business Constraints .. 5 Business Risks .. 5 2 Solution Context .. 5 3 Business Process Inventory .. 6 4 Domain Model .. 7 Accounts and Funds Transfers .. 7 Settlement Accounts .. 8 Settlement Concepts .. 8 Payment Domain Concepts .. 9 5 Solution Architecture Pattern .. 10 6 Processing Claims from Providers .. 11 Business Process Design .. 11 Process-Pattern 11 7 Business Process 2 .. 13 8 Business Process n .. 13 9 Addressing Non-Functional Solution Requirements .. 13 Performance .. 13 Availability within a Data Center .. 13 Site Disaster Recovery .. 15 Security .. 16 10 Payment Manager Service .. 16 Business Process Involvement .. 16 Interfaces .. 19 Observable 20 Observable State .. 20 Coordination .. 21 Constraints .. 22 Non-Functional 23 Performance .. 23 Availability within a Data Center.

3 23 Site Disaster Recovery .. 23 Security .. 23 11 Claim Router .. 23 Business Process Involvement .. 23 Interfaces .. 24 Observable 24 Observable State .. 25 Coordination .. 25 Document Document Title Here 3 Constraints .. 25 Non-Functional 25 12 Claim Processor .. 26 Business Process Involvement .. 26 Interfaces .. 27 Observable 27 Observable State .. 27 Coordination .. 27 Constraints .. 27 Non-Functional 27 13 Membership Service .. 27 Business Process Involvement .. 27 Interfaces .. 28 Observable 28 Observable State .. 28 Coordination .. 28 Constraints .. 29 Non-Functional 29 14 Provider Service .. 29 Business Process Involvement .. 29 Interfaces .. 29 Observable 29 Observable State .. 29 Coordination .. 29 Constraints .. 29 Non-Functional 30 15 Benefits Service.

4 30 Business Process Involvement .. 30 Interfaces .. 30 Observable 30 Observable State .. 30 Coordination .. 30 Constraints .. 30 Non-Functional 30 16 Banking Service .. 31 Business Process Involvement .. 31 Interfaces .. 31 Observable 31 Observable State .. 32 Coordination .. 32 Constraints .. 32 Non-Functional 32 17 Claim Tracker .. 32 Business Process Involvement .. 32 Interfaces .. 32 Observable 32 Document Document Title Here 4 Observable State .. 33 Coordination .. 33 Constraints .. 34 Non-Functional 34 18 HTTP-JMS Mediation .. 34 Business Process Involvement .. 34 Interfaces .. 34 Observable 34 Observable State .. 34 Coordination .. 34 Constraints .. 34 Non-Functional 34 19 Deployment .. 34 Deployment Environment Migration .. 34 Development Configuration.

5 34 Test Configuration .. 35 Production 35 20 Integration and Testing Requirements .. 35 Integration Strategy .. 35 Behavioral Testing .. 35 Performance Testing .. 35 Performance Testing .. 35 Appendix A: Common Data Format Specifications .. 35 Appendix B: Message Format Specifications .. 35 Appendix C: Service Interface Specifications .. 35 Appendix D: Data Storage Specifications .. 35 Document Document Title Here 5 1 Business Objectives and Constraints Nouveau Health Care is a traditional Health care insurance company. It sells Health care insurance policies and covers claim payments with the revenue it collects from its premiums. It also administers the processing of claims. There are some additional factors that add to the complexity of Nouveau s business. In some cases, the employers who provide the Health care benefits for their employees also provide the funds for paying the claims: Nouveau administers the policies.

6 In other cases the administration of specialized services (vision and dental care) is farmed out to other companies. Quantified Business Expectations For business reasons, Nouveau Health Care needs to be able to engage business partners specializing in claim payment processing for particular kinds of Health care ( vision, pharmaceuticals). The objective is to standardize the means by which Nouveau interacts with these business partners and implement a claim payment Architecture based on that standard. In the first release, interactions with VisionCare (a business partner) will be implemented to allow them to process Nouveau s vision claims. Business Constraints It is expected that this project will take 18 months and involve a team of 25 full-time-equivalent Nouveau personnel over that time period, with a budget of $6million.

7 VisionCare resources are not included in this budget, although they are committed to completing their side of the project in this time frame. Business Risks A failure in the processing of a single claim results in the need for manual intervention in the processing of the claim. This results in a 100x increase in the cost of processing a claim. Since there is only a 5% profit in the automated processing of a claim, a single manual process eliminates the profit from 2,000 automated processes. As a result, the overall failure rate of the automated process should be maintained at less than one in 100,000 claims. Nouveau Health Care processes million claims a day. The cost of processing an electronic claim submission is $.85, while the cost of processing a paper claim is $ The impact of the electronic process being unavailable is that the claim is likely to be submitted as a paper claim, with a resulting cost increase of $ per claim.

8 Since claims arrive during peak periods at a rate of 550,000 per hour, the cost of a system outage is $550,000 per hour. Consequently, the availability of the automated business process should be maintained at with a maximum outage time of 5 minutes per incident. This allows a maximum of 5 outages/year, with anticipated annual outage costs totaling $230,000 per year. Reasonable investments that can further reduce this anticipated annual outage cost, and have a reasonable payback period, are desirable. 2 Solution Context Nouveau Health Care is part of a larger environment that includes the Health care service providers that submit claims and the partner companies that process some of the claims (Figure 2-1). Here we see that there can be more than one claim processor, which explains the need for the Claim Router. Document Document Title Here 6 Figure 2-1 Nouveau Health Care in Context 3 Business Process Inventory This Solution focuses on four business processes (Figure 3-1): [lb] Validate Membership and its underlying Validate Membership Service [lb] Manage Payments, which manages claim payments to Health care service providers.

9 [lb] Process Claim, and its initiator, Route Claim, which together handle the processing of insurance claims. [lb] Monitor Claim Processing, a process that monitors the execution of claim processing. Figure 3-1 Nouveau Health Care Business Processes : Nouveau Claim Processor : Claim Process Monitor : Payment Manager : Member Service : Provider Service : Benefits Service : Banking Service : Claim Router : Nouveau Health Care : Partner Claim Processor : Billing ProviderArchitecting BPM solutions with TIBCOA rchitecting Complex Event Processing solutions with TIBCOTIBCO Architecture FundamentalsArchitecting Composite Applications and Services with TIBCO : Monitor Claim Processing : Claim Payment Response : Validate Membership : Validate Membership Service : Manage Payments : Process Claim : Claim Submission : Claim Payment Request : Route Claim.

10 Eventclaim processing eventrequestprocessing eventsreplyDocument Document Title Here 7 The Validate Membership process is used by authorized parties ( Health care providers, employers, and members) to validate whether or not an individual was covered by the policy on a given date. This business process utilizes an underlying Validate Membership Service, which is also used by the Process Claim business process. The Manage Payments process manages the payments to Health care service providers resulting from Health care What makes this process interesting is that, under normal circumstances, payments are made on a periodic basis ( monthly) to Health care service providers. This means that the payment manager must keep track of pending payments. By exception, payments to Health care service providers for specific claims may be made immediately.