n8n-nodes-trizetto

[Velocity BPA Licensing Notice]

This n8n node is licensed under the Business Source License 1.1 (BSL 1.1).

Use of this node by for-profit organizations in production environments requires a commercial license from Velocity BPA.

For licensing information, visit https://velobpa.com/licensing or contact [email protected].

A comprehensive n8n community node package for TriZetto healthcare clearinghouse integration. Provides complete EDI transaction support (270/271, 276/277, 837, 835), real-time eligibility verification, claims management, remittance processing, prior authorization workflows, and revenue cycle management capabilities.

Features

• Eligibility Verification (270/271) - Real-time and batch eligibility checks with comprehensive benefits parsing
• Claim Submission (837) - Professional, Institutional, and Dental claim submission with validation
• Claim Status (276/277) - Track claim status with detailed event history
• Remittance Processing (835) - Parse ERA files, reconcile payments, extract adjustment codes
• Prior Authorization - Submit, track, and manage prior auth requests
• Provider Management - NPI validation, network status, credentialing
• Payer Directory - Payer rules, EDI requirements, connectivity testing
• Code Validation - ICD-10, CPT, HCPCS, revenue code validation with CCI edits
• Batch Processing - Submit and monitor batch file processing
• EDI Operations - Parse/generate X12 transactions, 997/999 acknowledgments
• Real-Time Transactions - Synchronous eligibility, claim status, cost estimates
• CareAdvance RCM - Work queues, task management, productivity tracking
• Reports & Analytics - A/R reports, denial analytics, clean claim rates
• SFTP Integration - File upload/download for batch processing
• Webhook Support - Event-driven notifications for claims, payments, authorizations

Installation

Community Nodes (Recommended)

1. Open n8n
2. Go to Settings > Community Nodes
3. Click Install a community node
4. Enter n8n-nodes-trizetto
5. Click Install

Manual Installation

# Navigate to your n8n installation
cd ~/.n8n

# Install the package
npm install n8n-nodes-trizetto

# Restart n8n

Development Installation

# Clone or extract the repository
git clone https://github.com/Velocity-BPA/n8n-nodes-trizetto.git
cd n8n-nodes-trizetto

# Install dependencies
npm install

# Build the project
npm run build

# Link to n8n custom nodes
mkdir -p ~/.n8n/custom
ln -s $(pwd) ~/.n8n/custom/n8n-nodes-trizetto

# Restart n8n
n8n start

Credentials Setup

TriZetto API Credentials

| Field | Description | Required | |-------|-------------|----------| | Environment | Production, Test/Staging, or Custom | Yes | | Username | TriZetto API username | Yes | | Password | TriZetto API password | Yes | | Client ID | OAuth client ID | Yes | | Client Secret | OAuth client secret | Yes | | Submitter ID | EDI submitter identifier | Yes | | Site ID | Site identifier (multi-site setups) | No | | Vendor ID | Vendor identifier | No |

TriZetto Gateway Credentials

| Field | Description | Required | |-------|-------------|----------| | Gateway URL | TriZetto Gateway endpoint | Yes | | Certificate | mTLS client certificate (PEM) | Yes | | Private Key | mTLS private key (PEM) | Yes | | Partner ID | Trading partner identifier | Yes |

TriZetto SFTP Credentials

| Field | Description | Required | |-------|-------------|----------| | Host | SFTP server hostname | Yes | | Port | SFTP port (default: 22) | Yes | | Username | SFTP username | Yes | | Authentication | Password or SSH Key | Yes | | Directory Path | Base directory path | No |

Resources & Operations

1. Eligibility (270/271)

• Check Eligibility - Real-time eligibility verification
• Batch Eligibility Check - Submit multiple eligibility requests
• Get Eligibility Response - Retrieve eligibility response by ID
• Get Benefits Summary - Get summarized benefits information
• Get Coverage Details - Retrieve detailed coverage information
• Get Deductible Info - Get deductible amounts and status
• Get Copay Info - Retrieve copay information by service type
• Get Coinsurance - Get coinsurance percentages
• Get Prior Auth Requirements - Check if prior auth is required
• Parse 271 Response - Parse raw 271 EDI response
• Get Eligibility History - Retrieve eligibility check history

2. Claim Submission (837)

• Submit Professional Claim (837P) - Submit CMS-1500 claims
• Submit Institutional Claim (837I) - Submit UB-04 claims
• Submit Dental Claim (837D) - Submit ADA dental claims
• Validate Claim - Pre-submission claim validation
• Get Claim Status - Check submission status
• Get Claim Acknowledgment - Retrieve 997/999 acknowledgment
• Batch Submit Claims - Submit multiple claims
• Get Submission History - View submission history
• Resubmit Claim - Resubmit with corrections
• Correct Claim - Submit claim correction

3. Claim Status (276/277)

• Check Claim Status - Real-time status inquiry
• Get Claim Status Response - Retrieve status response
• Get Detailed Status - Get detailed claim status with events
• Get Status by Claim ID - Query by claim identifier
• Get Status by Patient - Query by patient information
• Parse 277 Response - Parse raw 277 EDI response
• Get Status History - View status inquiry history

4. Remittance (835)

• Get Remittance Advice - Retrieve ERA by ID
• List Remittances - List all remittance advices
• Get ERA by Check Number - Find ERA by check/EFT number
• Get ERA by Date - Find ERAs by date range
• Parse 835 Response - Parse raw 835 EDI file
• Get Payment Details - Extract payment details from ERA
• Get Adjustment Codes - Get CARC/RARC codes from ERA
• Get Remark Codes - Extract remark codes
• Reconcile Payments - Match payments to claims
• Download ERA File - Download raw 835 file

5. Prior Authorization

• Submit Prior Auth Request - Submit new authorization request
• Check Prior Auth Status - Check authorization status
• Get Prior Auth Response - Retrieve authorization response
• Update Prior Auth - Modify existing authorization
• Cancel Prior Auth - Cancel authorization request
• Get Auth History - View authorization history
• Get Required Auth Info - Get payer auth requirements

6. Attachment

• Submit Attachment - Submit claim attachment
• Get Attachment Status - Check attachment status
• List Attachments - List claim attachments
• Link to Claim - Associate attachment with claim
• Get Attachment Types - Get supported attachment types
• Get PWK Codes - Get PWK segment codes
• Upload Document - Upload attachment document

7. Provider

• Get Provider Info - Retrieve provider information
• Search Providers - Search provider directory
• Validate NPI - Validate NPI format and checksum
• Get Provider by NPI - Lookup provider by NPI
• Get Provider Network Status - Check network participation
• Get Enrolled Providers - List enrolled providers
• Get Provider Credentials - Get credentialing information

8. Payer

• Get Payer List - List all payers
• Get Payer Info - Get payer details
• Get Payer by ID - Lookup payer by ID
• Get Payer Rules - Get billing rules and requirements
• Get Payer EDI Requirements - Get EDI specifications
• Get Trading Partner Info - Get trading partner details
• Check Payer Connectivity - Test payer connection

9. Patient

• Search Patients - Search patient records
• Get Patient Info - Retrieve patient information
• Get Patient by Member ID - Lookup by member ID
• Get Patient Demographics - Get demographic data
• Get Patient Coverage - Get coverage information
• Get Patient Claims - List patient claims
• Get Patient History - View patient history

10. Facility

• Get Facilities - List facilities
• Get Facility Info - Get facility details
• Validate Facility NPI - Validate facility NPI
• Get Facility Providers - List providers at facility
• Get Facility Payers - List contracted payers

11. Code Validation

• Validate ICD-10 Code - Validate diagnosis code
• Validate CPT Code - Validate procedure code
• Validate HCPCS Code - Validate HCPCS code
• Validate Revenue Code - Validate revenue code
• Get Code Description - Get code description
• Get Code Edits - Get coding edits/rules
• Check CCI Edits - Check CCI bundling rules
• Get LCD/NCD Info - Get coverage determinations
• Get Modifier Rules - Get modifier requirements

12. Batch

• Submit Batch File - Submit batch for processing
• Get Batch Status - Check batch status
• Get Batch Results - Retrieve batch results
• Get Batch Errors - Get batch errors
• Download Batch Response - Download response file
• List Batches - List all batches
• Cancel Batch - Cancel pending batch

13. EDI

• Submit EDI Transaction - Submit X12 transaction
• Get EDI Response - Get transaction response
• Get 997/999 Acknowledgment - Retrieve functional ack
• Get TA1 Acknowledgment - Retrieve interchange ack
• Parse EDI File - Parse X12 file
• Generate EDI File - Generate X12 from data
• Validate EDI Format - Validate EDI structure
• Get EDI History - View EDI transaction history

14. Real-Time

• Real-Time Eligibility - Synchronous eligibility check
• Real-Time Claim Status - Synchronous status check
• Real-Time Estimate - Get patient cost estimate
• Real-Time Prior Auth - Synchronous auth check

15. CareAdvance (RCM)

• Get Work Queue - Retrieve work queue items
• Get Tasks - List assigned tasks
• Complete Task - Mark task complete
• Reassign Task - Reassign to another user
• Get Task History - View task history
• Get Productivity Stats - Get productivity metrics

16. Report

• Generate Report - Create new report
• Get Report - Retrieve report by ID
• List Reports - List available reports
• Schedule Report - Schedule recurring report
• Get A/R Report - Get accounts receivable report
• Get Denial Report - Get denial analysis report
• Get Payment Report - Get payment summary report
• Export Report - Export report to file

17. Analytics

• Get Revenue Analytics - Revenue performance metrics
• Get Denial Analytics - Denial trends and analysis
• Get Clean Claim Rate - Calculate clean claim rate
• Get Days in A/R - Calculate days in A/R
• Get First Pass Rate - First pass payment rate
• Get Payer Performance - Payer performance metrics

18. Clearinghouse

• Get Clearinghouse Status - Check clearinghouse status
• Get Trading Partners - List trading partners
• Get Connection Status - Check connection health
• Test Connection - Test payer connectivity
• Get Enrollment Status - Check enrollment status

19. Enrollment

• Get Enrollment Status - Check payer enrollment
• Submit Enrollment - Submit new enrollment
• Get Enrolled Payers - List enrolled payers
• Update Enrollment - Update enrollment info
• Get Enrollment Requirements - Get enrollment requirements

20. SFTP

• Upload File - Upload file to SFTP
• Download File - Download file from SFTP
• List Files - List directory contents
• Get File Status - Check file status
• Delete File - Delete file
• Get Directory - Get directory listing

21. Webhook

• Create Webhook - Register new webhook
• Get Webhook - Get webhook details
• Update Webhook - Update webhook configuration
• Delete Webhook - Remove webhook
• List Webhooks - List all webhooks
• Verify Webhook - Verify webhook signature

22. Utility

• Validate NPI - Validate NPI number
• Validate Tax ID - Validate Tax ID/EIN
• Get Place of Service Codes - List POS codes
• Get Taxonomy Codes - List taxonomy codes
• Get Adjustment Reason Codes - List CARC codes
• Get Remark Codes - List RARC codes
• Test Connection - Test API connectivity
• Get API Status - Get API health status

Trigger Node

The TriZetto Trigger node monitors for real-time events:

Eligibility Events

• Eligibility Response Received
• Eligibility Error
• Coverage Changed

Claim Events

• Claim Acknowledged
• Claim Accepted
• Claim Rejected
• Claim Paid
• Claim Denied
• Claim Status Changed

Remittance Events

• ERA Received
• Payment Posted
• Adjustment Applied
• Zero Pay Alert

Prior Auth Events

• Authorization Approved
• Authorization Denied
• Authorization Pending
• Authorization Expiring

Batch Events

• Batch Submitted
• Batch Completed
• Batch Error
• Acknowledgment Received

EDI Events

• 997/999 Received
• TA1 Received
• EDI Error

Task Events

• Task Assigned
• Task Due
• Task Completed

Report Events

• Report Ready

Usage Examples

Eligibility Verification

// Real-time eligibility check
{
  "resource": "eligibility",
  "operation": "checkEligibility",
  "payerId": "BCBS001",
  "memberId": "ABC123456789",
  "firstName": "John",
  "lastName": "Smith",
  "dateOfBirth": "1980-01-15",
  "serviceType": "30" // Health benefit plan coverage
}

Claim Submission

// Submit professional claim (837P)
{
  "resource": "claimSubmission",
  "operation": "submitProfessional",
  "payerId": "AETNA01",
  "patientInfo": {
    "memberId": "XYZ789012",
    "firstName": "Jane",
    "lastName": "Doe",
    "dateOfBirth": "1975-06-20"
  },
  "providerNpi": "1234567893",
  "diagnosisCodes": ["J06.9", "R05.9"],
  "serviceLines": [
    {
      "cptCode": "99213",
      "modifiers": ["25"],
      "chargeAmount": 150.00,
      "units": 1,
      "serviceDate": "2024-01-15",
      "placeOfService": "11"
    }
  ]
}

Remittance Processing

// Parse 835 ERA file
{
  "resource": "remittance",
  "operation": "parse835",
  "ediContent": "ISA*00*...(835 content)...IEA*1*000000001~"
}

// Get payment details
{
  "resource": "remittance",
  "operation": "getPaymentDetails",
  "remittanceId": "ERA20240115001"
}

Prior Authorization

// Submit prior auth request
{
  "resource": "priorAuth",
  "operation": "submit",
  "payerId": "UHC001",
  "memberId": "MEM123456",
  "providerNpi": "1234567893",
  "serviceType": "3", // Consultation
  "procedureCode": "27447",
  "diagnosis": ["M17.11"],
  "requestedUnits": 1,
  "clinicalInfo": "Patient requires knee replacement due to severe osteoarthritis"
}

Code Validation

// Validate ICD-10 code
{
  "resource": "codeValidation",
  "operation": "validateIcd10",
  "code": "M17.11"
}

// Check CCI edits
{
  "resource": "codeValidation",
  "operation": "checkCci",
  "primaryCode": "99213",
  "secondaryCode": "99214"
}

Batch Processing

// Submit batch file
{
  "resource": "batch",
  "operation": "submit",
  "fileType": "837P",
  "content": "(batch file content)"
}

// Check batch status
{
  "resource": "batch",
  "operation": "getStatus",
  "batchId": "BATCH20240115001"
}

TriZetto Concepts

Gateway

The TriZetto Gateway is the central hub for EDI transactions, routing claims and eligibility requests to appropriate payers.

CareAdvance

Revenue Cycle Management (RCM) platform for work queue management, task assignment, and productivity tracking.

Clearinghouse

EDI intermediary that validates, translates, and routes healthcare transactions between providers and payers.

Trading Partner

A payer connection established through enrollment, defining EDI requirements and routing rules.

X12 Transactions

• 270/271 - Eligibility Inquiry/Response
• 276/277 - Claim Status Inquiry/Response
• 837P/I/D - Professional/Institutional/Dental Claims
• 835 - Electronic Remittance Advice (ERA)
• 997/999 - Functional Acknowledgment
• TA1 - Interchange Acknowledgment

CARC/RARC Codes

• CARC (Claim Adjustment Reason Code) - Explains payment adjustments
• RARC (Remittance Advice Remark Code) - Additional explanation

Error Handling

The node provides detailed error information:

{
  "error": {
    "code": "INVALID_NPI",
    "message": "NPI checksum validation failed",
    "details": {
      "npi": "1234567890",
      "expected_check_digit": "3",
      "actual_check_digit": "0"
    }
  }
}

Common Error Codes

| Code | Description | |------|-------------| | AUTH_FAILED | Authentication failed | | INVALID_NPI | Invalid NPI format or checksum | | PAYER_NOT_FOUND | Payer ID not found | | CLAIM_VALIDATION_ERROR | Claim failed validation | | EDI_PARSE_ERROR | EDI parsing error | | TIMEOUT | Request timeout | | RATE_LIMIT | Rate limit exceeded |

Security Best Practices

1. PHI Protection - Never log or expose PHI in clear text
2. Credential Security - Use n8n's credential store
3. TLS/mTLS - All connections use TLS; Gateway uses mTLS
4. Audit Logging - All transactions are logged for HIPAA compliance
5. Access Control - Implement proper user access controls
6. Data Minimization - Only request necessary patient data

Development

# Install dependencies
npm install

# Build the project
npm run build

# Run tests
npm test

# Run tests with coverage
npm run test:coverage

# Lint code
npm run lint

# Fix linting issues
npm run lint:fix

# Watch mode for development
npm run dev

Author

Velocity BPA

• Website: velobpa.com
• GitHub: Velocity-BPA
• Email: [email protected]

Licensing

This n8n community node is licensed under the Business Source License 1.1.

Free Use

Permitted for personal, educational, research, and internal business use.

Commercial Use

Use of this node within any SaaS, PaaS, hosted platform, managed service, or paid automation offering requires a commercial license.

For licensing inquiries: [email protected]

See LICENSE, COMMERCIAL_LICENSE.md, and LICENSING_FAQ.md for details.

Contributing

1. Fork the repository
2. Create a feature branch (git checkout -b feature/amazing-feature)
3. Commit your changes (git commit -m 'Add amazing feature')
4. Push to the branch (git push origin feature/amazing-feature)
5. Open a Pull Request

Support

• Documentation: TriZetto Developer Portal
• Issues: GitHub Issues
• Community: n8n Community Forum
• Enterprise Support: Contact [email protected]

Acknowledgments

• n8n - Workflow automation platform
• TriZetto - Healthcare technology solutions
• X12 - EDI standards organization