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Medicaid Encounter Processing System: Integration & Trading Partner Test Plan
Executive Summary: This deliverable defines the end-to-end testing lifecycle for migrating legacy on-premise Medicaid encounter processing to a cloud-native AWS architecture. It details component verification, ANSI X12 EDI standards compliance, Business Rules Engine (BRE) execution, and trading partner onboarding.
1. Document Purpose & Scope
This document establishes the formal roadmap for verifying that the cloud-hosted Encounter Processing System (EPS) correctly ingests, adjudicates, and reports Medicaid managed care encounters in strict alignment with state business rules and federal HIPAA/EDI guidelines.
- Section I: Integration Test Plan: Outlines internal subsystem testing across Managed File Transfer (MFT), EDI Gateway, Encounter Processing Engine (EPE), Business Rules Engine (BRE), and Datastore layers.
- Section II: Trading Partner Test (TPT) Plan: Defines the external validation lifecycle and Work Breakdown Structure (WBS) required for Managed Care Organizations (MCOs) prior to production cutover.
2. Architecture & Subsystem Boundaries
| Component | Technology | Validation Responsibilities |
|---|
| Ingestion & Transfer | Managed File Transfer (MFT / GoAnywhere) | Validates secure SFTP payload receipt, file naming taxonomy, certificate authentication, and automated archive routing. |
| Compliance Checker | EDI Gateway | Executes WEDI SNIP Level 1–5 syntax and semantic validation across ANSI X12 837 Institutional (837I) and 837 Professional (837P) formats. |
| Adjudication Engine | Encounter Processing Engine (EPE) | Evaluates business rules, duplicate detection algorithms, historical cross-references, and state-specific Medicaid coverage policies. |
| Business Rules | Business Rules Engine (BRE) | Applies custom logic tables, modifier combinations, and provider-taxonomy compatibility matrices. |
3. Test Data Management & Code Sets
External Code Sets (SNIP Level 5 Validation)
- HCPCS / CPT: Procedure and service codes (External Code Set 130)
- Revenue Codes: National Uniform Billing Committee (NUBC) facility codes (Code Set 132)
- ICD-10-CM / ICD-10-PCS: Diagnostic and inpatient procedure coding (Code Sets 896 & 897)
- NDC: National Drug Code directory for physician-administered medications (Code Set 240)
Internal Cache Code Sets (State Business Rules)
| Code Set Identifier | Data Scope | Adjudication Purpose |
|---|
ACCOMDIN | Inpatient Accommodation Codes | Validates room and board rate compliance against contracted facility tier limits. |
BILLTYPEINP12 | Institutional Bill Types | Restricts interim bill submissions to authorized acute care and specialty facilities. |
CLAIMFREQ837I / P | Claim Frequency Codes | Validates replacement, void, and original submission logic across historical encounters. |
4. Defect Life Cycle & Governance
- Identification: Tester logs variance between observed output and expected business rules.
- Documentation: Ticket populated with transaction control numbers (TCN), X12 element loops, raw payload snippets, and error codes.
- Triage & Classification: Defect triaged into New Defect, Duplicate, Deferred, Rejected, or Requirement Change.
- Remediation: Assigned engineering team applies code corrections or BRE spreadsheet updates.
- Unit Verification: Developer confirms correction in containerized local test harness.
- Regression Retest: QA executes regression test pack across affected transaction sets.
- Closure: Test Manager approves formal sign-off once verified across both 837I and 837P streams.