In June 2020, CMS awarded the contract to Flexion, and we began our work to design the Data Systems Architecture Modernization (DSAM) system to provide quality assurance and statistical data analysis of Part A and B Medicare claims healthcare data transmitted from the Common Working File (CWF).

The intention was to process Medicare Part A and B claims for downstream internal CMS business units, including:

• National Claims History (NCH),
• Integrated Data Repository (IDR),
• Chronic Conditions Data Warehouse (CCW), and more.

We also considered the needs of analysts who require information for reporting purposes in our design specifications.

The team needed to design a modernized system that could:

• Receive claims data in Extended Binary Coded Decimal Interchange Code (EBCDIC) format.
• Perform quality validations.
• Provide the data for consumption by downstream systems daily and weekly to meet the existing Service Level Agreement (SLA).
• Match existing output to downstream systems so they did not have to change coding.

The Flexion team utilized several Amazon Web Service (AWS) tools, including AWS Batch to scale parsing and building of the large data field, AWS Lambda to scale parallel processing of claims data, Amazon Elastic Compute Cloud (Amazon EC2) to connect with the external data center and transfer files, and AWS Elastic File System for data storage between Amazon EC2 and AWS Lambda. Claims data was stored in AWS Simple Storage Service (AWS S3) through various stages, and AWS Athena was leveraged for metadata and other data querying needs.

Focusing on incremental vertical slices of functionality, the team designed a modern cloud infrastructure and tools with the flexibility to leverage future AWS offerings.

The outcome of this work resulted in the ability to:

• Ingest claims data sent from the CWF in EBCDIC from mainframe systems in the CMS Baltimore Data Center.
• Translate the claims data to JavaScript Object Notation (JSON) to provide a flexible, modern data format for analysis and transformation.
• Perform quality checks and validations on the claims data.
• Store valuable claims metadata utilizing AWS Athena to provide directional data points to solve business problems, such as identifying the prevalence of fraud and claim accuracy and informing stakeholders of Medicare claim quality, anomalies, and system performance.
• Transform the JSON data into a format matching the downstream consuming systems received from the legacy system.
• Deliver quality-checked Medicare claims for long-term storage and access through NCH and IDR and support daily and weekly satellite systems that meet the individual systems’ SLA.

The team delivered a Medicare Part A and B claims processing and quality assurance application with minimal disruption to downstream systems by matching existing claim output data, all on a platform allowing system modification and evolution using modern technologies. Flexion delivered the system to production in October 2022 and supported it in production until September 2023.