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TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference

Manual

7 | Introduction

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Summary of Contents for Foresight HIPAA Validator

Page 1: ...TIBCO Foresight HIPAA Validator Desktop Standards and Guidelines Reference Manual Version 9 2 0 February 2022 Copyright 2001 2022 TIBCO Software Inc All Rights Reserved ...

Page 2: ... GuideMerge 6 Standards Overview 8 Supported Standards 9 Pre X12 Standards 9 X12 Standards 10 X12 Derivatives 12 Medical Standards 13 EDIFACT Standards 14 EDIFACT Derivatives 16 Other Standards 16 XML Standards 17 Flat File Standards 17 Guideline Overview 18 Life Cycle of a Guideline 18 Using a Merged Guideline 19 Anatomy of a Guideline 23 Explanation for Segment Table Example 24 Explanation for S...

Page 3: ...endix A HL7 Standards 39 HL7 in TIBCO Foresight Products 39 Sample Data and Instream Scripts 40 Big Picture 40 HL7 Specific Information 41 HL7 Data Types 45 Appendix B NCPDP Standards 49 NCPDP in TIBCO Foresight Products 49 Sample Data and Instream Scripts 50 Terminology 50 Big Picture 51 Codes 52 Elements 52 Segments 55 Example Batch 57 Data with no 1 1 Enveloping 58 TIBCO Documentation and Suppo...

Page 4: ...idelines are those related to healthcare pharmacies and transportation logistics Customized Guidelines Customized guidelines are those you develop using a published standard or guideline as a starting point They further define rules in places where the standard or industry guideline is not specific enough or you need specialized behavior Customized guidelines are also referred to as companion guid...

Page 5: ...anion guidelines for use during EDI transaction processing and validation Create company guidelines Uses guidelines to print documentation make test data validate types 1 2 and 8 migrate guidelines to new version view parts of guideline HIPAA Validator Desktop l Validates data according to industry standards custom guidelines and specific business rules l Provides the ability to correct data Uses ...

Page 6: ...line Merging with GuideMerge Production guidelines are guidelines for Instream and HIPAA Validator Desktop that you create by merging a user guideline with a TIBCO Foresight guideline HIPAA based Production guidelines contain type 1 7 edits GuideMerge installs with HIPAA Validator Desktop EDISIM and Windows versions of Instream Guideline Merge lets you merge the changes that you have made to your ...

Page 7: ...TIBCO Foresight HIPAA Validator Desktop Standards and Guidelines Reference Manual 7 Introduction ...

Page 8: ...ed variable length fields Standards can contain many different transaction types For example X12 standards provide rules for hundreds of different transactions often known by their numbers like these common ones 810 Invoice 850 Purchase Order 856 Shipping Notice 997 Functional Acknowledgment 999 Acceptance Rejection Advice Supported Standards provides a detailed list of the standards and guideline...

Page 9: ...Desktop Additionally these TIBCO Foresight products support general XML schema and flat file definitions although they do not currently ship with organization schemas e g MISMO Please see XML Standards and Flat File Standards for more information Pre X12 Standards Version Shipped with EDISIM Shipped with Instream HIPAA Validator Desktop AIR 24 25 26 27 Yes No FREIG 26 27 Yes No MOTOR 23 24 25 26 2...

Page 10: ... with Instream HIPAA Validator Desktop 2000 Yes No 2001 Yes No 2002 Yes No 2003 Yes No 2040 Yes No 3010 Yes No 3020 Yes No 3030 3031 3032 Yes No 3040 3041 3042 Yes No 3050 3051 3052 Yes No 3060 3061 3062 Yes No 3070 3071 3072 Yes No 4010 4011 4012 Yes 4010 only 4020 4021 4022 Yes No 4030 4031 4032 Yes No 4040 4041 4042 Yes No 4050 4051 4052 Yes 4050 only ...

Page 11: ...s No 5010 5011 5012 Yes 5010 only 5020 5021 5022 Yes No 5030 5031 5032 Yes No 5040 5041 5042 Yes 5040 only Instream only 5050 5051 5052 Yes 5050 only 6010 6011 6012 Yes Yes 6020 6021 6022 Yes Yes 6030 6031 6032 Yes Yes 6040 6041 6042 Yes Yes 6050 6051 6052 Yes Yes 7010 7011 7012 Yes No 7020 7021 7022 Yes No 7030 7031 7032 Yes No 7040 7041 7042 Yes No 7050 7051 7052 Yes No 7060 Yes No 8010 Yes No ...

Page 12: ...Level 1 2 Yes Yes HIPAA Levels 3 7 No see note Yes UCS 3030 3040 3050 3060 3070 4010 4020 4030 4040 4050 5010 Yes No VICS 2003 3010 3020 3030 3040 3050 3060 3070 4010 4020 4030 4040 4050 5010 Yes No Note The HIPAA Level 3 through 7 guidelines are encrypted within Instream and HIPAA Validator Desktop EDISIM will allow the creation of guidelines with additional rules that can be merged with these en...

Page 13: ... Editor Reference Validator only Yes Medicaid pharmacy subrogation NCPDP Telecom D 0 Batch 1 2 Editor Validator only Yes NCPDP Telecom 5 1 Batch 1 1 Editor Validator only Yes NCPDP Telecom D 0 Batch 1 2 Editor Validator only Yes NCPDP Post Adjudication 4 2 NCPDP_PAH42 sef and NCPDP_PAU42 sef Editor Validator only Yes NSF 3 1 Editor Validator only Yes UB 92 6 0 Editor Validator only Yes does not sh...

Page 14: ...40ICS Yes Instream only UN41ICS Yes Instream only UN 901 901v4 902 902v4 Yes No UN 911 911v4 912 912v4 Yes No UN 921 921v4 Yes No UNCTRL Yes No D93A D93Av4 Yes D93A only Instream only S93A S93Av4 Yes No D94A D94Av4 D94B D94Bv4 Yes No D95A D95Av4 D95B D95Bv4 Yes No D96A D96Av4 D96B D96Bv4 Yes D96A only Instream only D97A D97Av4 D97B D97Bv4 Yes No D98A D98Av4 D98B D98Bv4 Yes No D99A D99Av4 D99B D99B...

Page 15: ...D03Av4 D03B D03Bv4 Yes No D04A D04Av4 D04B D04Bv4 Yes No D05A D05Av4 D05B D05Bv4 Yes No D06A D06Av4 D06B D06Bv4 Yes No D07A D07Av4 D07B D07Bv4 Yes No D08A D08Av4 D08B D08Bv4 Yes No D09A D09Av4 D09B D09Bv4 Yes No D10A D10Av4 D10B D10Bv4 Yes No D11A D11AV4 D11B D11BV4 Yes No D12A D12AV4 D12B D12BV4 Yes No D13A D13AV4 D13B D13BV4 Yes No D14A D14AV4 D14B D14BV4 Yes No D15AC D15AV4 D15B D15BV4 Yes No D...

Page 16: ...AV4 D20B D20BV4 Yes No These standards contain 5 digit sequence numbers Install EDISIM 6 18 0 or later before using these standards EDIFACT Derivatives Version Shipped with EDISIM Shipped with Instream HIPAA Validator Desktop EANCOM93 Yes No EAN97 Version 3 and 4 Yes No EAN02 Syntax 3 and 4 Yes No Other Standards Version Shipped with EDISIM Shipped with Instream HIPAA Validator Desktop ACH ACH_CCD...

Page 17: ...n be saved as a standard and used in EDISIM Validator and Instream HIPAA Validator Desktop to validate XML data and to create HTML reports of validation results EDISIM TDG does not support XML schemas Flat File Standards EDISIM Standards Editor lets you create both fixed length and delimited flat file guidelines along with custom enveloping You can use these flat file guidelines in EDISIM Validato...

Page 18: ...eline as a starting point They further define rules in places where the standard or industry guideline is not specific enough or you need specialized behavior to use the guideline with other Foresight products such as Dataswapper or Transaction Insight For example you may want to mark certain optional fields as not used add internal notes etc Customized guidelines are also referred to as companion...

Page 19: ... n n _fseditor pdf After saving Our837P will have types 1 2 and 8 our specifications are considered type 8 Using a Customized Guideline with EDISIM Once defined in Standards Editor the guideline is actually a STD file in EDISIM s User Files Public Guidelines directory From there it is available to all other EDISIM modules Using a Merged Guideline Merging Guidelines Since EDISIM can only handle HIP...

Page 20: ...ideline the one to be used with the HIPAA products GuideMerge pdf gives all the details Let s assume that we are doing the merge from a machine that is running Instream Here s what we would do 1 Copy Our837P from EDISIM s User Files Public Guideline directory to somewhere on the Instream machine 2 Run GuideMerge to create P_Our837P std Using Merged Guidelines with Instream Copy the resulting P_Our...

Page 21: ...ot need the APF customer errors file etc Using Merged Guidelines with Transaction Insight The web portal machine must have an installation of Instream with the same guidelines and related files that were used for validation After initial validation the detail results file is imported into Transaction Insight A Transaction Insight user corrects the data and it is sent to Instream to revalidate Typi...

Page 22: ...TIBCO Foresight HIPAA Validator Desktop Standards and Guidelines Reference Manual 22 Guideline Overview A more complete overview of a typical process like this might be ...

Page 23: ... Validator Desktop Standards and Guidelines Reference Manual 23 Anatomy of a Guideline Anatomy of a Guideline The following pages show an annotated example guideline document Unused segments were not printed in this example ...

Page 24: ... The next one is a level 2 note In this example the names of the note levels have been changed in Standards Editor Use File Properties Level Notes tab Slowly click on the Note Name in the bottom of the dialog box and type the name To insert or change notes on the first page of the guideline document click on the transaction or message click Edit Notes in the bottom pane s Detail tab select the lev...

Page 25: ...can change this in EDISIM Standards Editor Click on the Loop header in the top pane and then change the Repeat Count field in the bottom pane s Detail tab L Transaction or message notes and comments from the original standard You cannot see or change them in EDISIM Standards Editor If you need to change them use EDISIM Doc Builder to export your guideline into a RTF file and open it in a word proc...

Page 26: ...ent Detail Page Example O Level Heading Detail etc in which the segment appears P Segment purpose You can change this in EDISIM Standards Editor Click on the segment in the top pane and then change the Purpose field in the bottom pane s Detail tab To change it throughout the transaction make the change in the Segments dictionary ...

Page 27: ... and use the Description field in the bottom pane s Detail tab You can also change it in the segment composite or element dictionaries if you want the change to be throughout the guideline U Attributes or representation You can change this in EDISIM Standards Editor Click on the element and use the bottom pane s Detail tab The information includes l Requirement If you have selected Single Attribut...

Page 28: ...lues only appear here if you have changed the original list from the originating standard You can change this list in EDISIM Standards Editor Click on the element in the top pane and use the Code Values tab at the bottom You can also work with codes in the element composite or segment dictionary To change a code s description purpose minimum maximum or type use the Element dictionary X Code value ...

Page 29: ... For customers who have licensed Instream Standard Edition you may not use any of the healthcare guidelines included in Instream Healthcare Edition Overview TIBCO Foresight guidelines Guidelines that ship with EDISIM Instream and HIPAA Validator Desktop HIPAA For those using TIBCO Foresight HIPAA validation products these guidelines in EDISIM contain types 1 and 2 edits HIPAA based TIBCO Foresight...

Page 30: ...LU Records Types 1 2 HIPAA Validator Desktop or Instream Non Addenda Types 1 7 HIPAA Validator Desktop or Instream Addenda No SVALU Recs Types 1 7 GuidelinePlus Instream only Addenda SVALU Recs Types 1 7 PDSA Types 1 2 PDSX PDF www wpc edi com Value in GS08 A1 at end Addenda Notes 270 Eligibility Coverage or Benefit Inquiry 270 A120 270AA120 4010270 B41A270 PDSA270 PDSX270 X092 pdf 004010X092 0040...

Page 31: ...for Review 278 A320 278ARES 41 278RP 41A278RP PDA278RP PDX278RP X094 pdf 004010X094 004010X094A1 BHT02 11 820 Payment Order Remittance Advice 820 A120 820AA120 4010 820 B41A820 PDSA820 PDSX820 X061 pdf 004010X061 004010X061A1 834 Benefit Enrollment and Maintenance 834 A120 834AA120 4010834 B41A834 PDSA834 PDSX834 X095 pdf 004010X095 004010X095A1 835 Health Care Claim Payment Advice 835 W120 835AW1...

Page 32: ...nt Name EDISIM Non Addenda Types 1 2 HIPAA Validator Desktop or Instream Addenda No SVALU Records Types 1 7 GuidelinePlus Instream only Addenda SVALU Records Types 1 7 Types 1 2 PDF www wpc edi com Value in GS08 Notes 275 Additional Information to Support a Health Care Claim or Encounter 275 X151 4050 275 n a 275 X151 pdf 004050X151 277 Health Care Claim Request for Additional Information 277 X150...

Page 33: ...12 PDSX5010277X212 277 X212 5010 pdf 005010X212 277 Health Care Claim Status Response Unsolicited 277U X212 277U X212 n a n a PDSX5010 277UX212 005010 005010X212 277 Health Care Claim Acknowledgement 277CA X214 277CA X214 5010 277CAX214 PDSA5010277CAX214 PDSX5010277CAX214 X214_ 277CA pdf 005010X214 277 Health Care Claim Status Response Medicare n a 5010 MEDICARE 277X212 PDSA5010MEDICARE 277X212 st...

Page 34: ...1 835 X221 5010 835 PDSA5010835 PDSX5010835 835 X221 5010 pdf 005010X221A1 837D Health Care Claims Dental 837 X224 837 X224 5010837D PDSA5010837D PDSX5010837D 837 x224 5010 pdf 005010X224A2 Uses SV1 segment 837I Health Care Claim Institutional 837 X223 837 X223 5010837I PDSA5010837I PDSX5010837I 837 x223 5010 pdf 005010X223A2 Uses SV3 segment 837I Health Care Claim Institutional Medicare A n a n a...

Page 35: ...X5010 277X213 277 X213 5010 pdf 005010X213 277 Health Care Claim Request for Additional Information 277 X313 277 X313 6020 277X313 PDSA6020 277X313 PDSX6020 277X313 277 X313 6020 pdf 006020X313 277 Data Reporting Acknowledgment 277 X364 277 X364 5010 277DRAX364 PDSA5010277DRAX364 277 X364 5010 pdf 005010X364 278 Health Care Services Review Information Inquiry 278X215I 278X215I 5010 278X215I PDSA50...

Page 36: ...Enrollment 834 X307 834 X307 5010 834X307 PDSA5010 834X307 PDSX5010 834X307 834 x307 5010 pdf 005010X307 834 Plan Member Reporting 834 X318 834 X318 5010 834X318 PDSA5010 834X318 PDSX5010 834X318 834 x318 5010 pdf 005010X318 837D Dental Post Adjudication Claims Data Reporting 837 X300 837 X300 5010 837X300 PDSA5010 837X300 PDSX5010 837X300 837 x300 5010 pdf 005010X300 837I Institutional Post Adjud...

Page 37: ... FSSD5010 277X212 FSSD5010 278X217REQ FSSD5010 278X217RES FSSD5010 820X218 FSSD5010 834X220 FSSD5010 835X221 FSSD5010 837DX224 FSSD5010 837IX223 FSSD5010 837PX222 FSSD5010 MEDICAREA FSSD5010 MEDICAREB Community Manager only For customers who host their own Community Manager merge these with your company guidelines to create production guidelines that contain scenarios Guidelines are installed in I...

Page 38: ... Carrier Freight Details and Invoice TIBCO Foresight Transaction Insight Standard Edition PDSAGM5010 210 IM 810 Invoice PDSAGM5010 810 IN 820 Payment Order Remittance Advice PDSAGM5010 820 RA 850 Purchase Order PDSAGM5010 850 PO 855 Purchase Order Acknowledgment PDSAGM5010 855 PR 856 Ship Notice Manifest PDSAGM5010 856 SH 860 Purchase Order Change Request Buyer Initiated PDSAGM5010 860 PC ...

Page 39: ...s l 2 3 l 2 3 1 l 2 4 l 2 5 1 l 2 6 are distributed with these TIBCO Foresight products l HIPAA Validator Desktop version 8 0 0 or later l Instream version 8 0 0 or later validation only You can use them with these modules of EDISIM 6 10 1 or later copy the appropriate standard for example HL7_26 std from Instream s or HIPAA Validator Desktop s Database folder to EDISIM s User Files Public Guideli...

Page 40: ...RUR01_HL7_ Clean script V_ORUR01_ HL7_Clean Scripts Validates HL7_ORU_R01_ Clean txt an HL7 file Big Picture Messages HL7 provides the following messages referred to in the X12 community as transaction types l Patient Administration l Order Entry l Queries l Financial Management l Observation Reporting l Master Files l Medical Records Information Management l Scheduling View Brief l Patient Referr...

Page 41: ... File segment is seen or upon end of file One or more messages may be grouped into a Batch which is explained below Parts of a Batch One or more messages may be grouped into a batch A batch l begins with a Start Batch Segment BHS l is followed by one or more messages l ends with an End Batch Segment BTS One or more batches may be grouped into a file A file l begins with a Start File Segment FHS l ...

Page 42: ...inology differences between X12 data and HL7 data are as follows X12 HL7 Interchange File Functional Group Batch Transaction Set Message Loop Segment Group Segment Segment Sub Composite Members Field Sub Components Element Fields Code Set Table Requirements Coding The following Requirements characters are used in the Requirements field in HL7 messages ...

Page 43: ...ce Manual 43 Appendix A HL7 Standards Character X12 Meaning HL7 Meaning M Mandatory Required O Optional Optional C Conditional Conditional X none Not Used B none Backward Compatibility W none Withdrawn Sub Composites Composites in HL7 transactions may contain sub composites ...

Page 44: ...rds Enveloping Enveloping differences between X12 data and HL7 data are as follows The HL7 segment Defined as Is like this segment in X12 FSH File Header Segment includes delimiter overrides ISA optional BSH Batch Header Segment includes delimiter overrides GS optional MSH Message Header Segment includes delimiter overrides ST none Message Trailer Segment SE BST Batch Trailer Segment GE optional b...

Page 45: ...is HL7 The 1 in front of the GEN record number is the line number in the data file HL7 Data Types The following data types are commonly found in HL7 transactions messages For additional information refer to the official HL7 documentation for Data Types http www hl7 org Data Type Description AD Address CCD Charge code and date CCP Channel calibration parameters CD Channel definiion CE Coded ENTRY C...

Page 46: ...E Coded with exceptions CX Extended Composite ID with check digit DLN Driver s license number DR Date time range DT Data ED Encapsulated data EI Entity identifier FC Financial class FN Family name FT Formatted text data HD Hierarchic designator ID Coded value for HL7 defined tables IS Coded value for user defined tables JCC Job code class MA Multiplexed array MO Money NA Numeric array ...

Page 47: ...location PN Person PPN Performing person time stamp SI Sequence ID PT Processing type QIP Query input parameter list QSC Query selection criteria RCD Row column definition RI Repeat interval RP Reference pointer SAD Street address SCV Scheduling class value pair SN Structured numeric SRT Sort order ST String data TM Time TQ Timing quantity TS Timestamp ...

Page 48: ...L7 Standards Data Type Description TX Text data VH Visiting hours VID Version identifier XAD Extended address XCN Extended composite ID number and name for persons XON Extended composite name and identification number for organizations XPN Extended person name XTN Extended telecommunications number ...

Page 49: ...1 1 for HIPAA NCPDP in TIBCO Foresight Products The NCPDP5 and NCPDPD0 guidelines are HIPAA specific and so are distributed with the following TIBCO Foresight products l HIPAA Validator Desktop version 4 1 or later l Instream version 4 1 or later validation including Trading Partner Automation only You can use it with these modules of EDISIM 5 13 or later copy NCPDP5 STD and NCPDPD0 STD from Instr...

Page 50: ...Request containing three G1 segments each with one claim NCPDP_ Response _ 51 txt DemoData A B2 Billing Reversal Response containing five G1 segments each containing segment 21 a Response Status Segment V_NCPDP_51_ BillRequest Scripts Validates NCPDP_BillRequest_ 51 txt Terminology X12 NCPDP Interchange Batch Functional Group none Transaction Set Transmission Loop none Claim or other application d...

Page 51: ...illing Reversal l B3 Billing Rebill Controlled Substance Reporting l C1 Controlled Substance Reporting l C2 Controlled Substance Reversal l C3 Controlled Substance Rebill Eligibility l E1 Eligibility Verification Information Reporting l N1 Information Reporting l N2 Information Reversal l N3 Information Rebill Prior Authorization l P1 Prior Authorization Request and Billing l P2 Prior Authorizatio...

Page 52: ...eader segment with ISA type information l One or more G1 detail records each containing one to four transactions such as claims l One 99 trailer containing a control number and segment count Codes NCPDP doesn t have actual code sets but the standard specifies allowed values These are implemented as code sets in TIBCO Foresight products Elements l The first value in a segment is AM followed by the ...

Page 53: ...in these formats nnn Only in batch control segments Example 303 nnn aa The usual NCPDP element ID The last two characters are called the element tag Since EDISIM and Library only allow up to four digits for element IDs they are abbreviated by taking out the third digit and the hyphen Example 101 7R becomes 107R in EDISIM The description will include the full ID Element Types Type As shown in EDISI...

Page 54: ...most character Positive Example To determine the EDI data for 19 95 look up the last digit 5 in the Value column of the chart below Now move to the right one column to find the value that would represent 5 and signed positive is E Therefore the positive value 19 95 appears as 199E in the data assuming the data type is N2 Negative Example To calculate the EDI data for minus 19 95 look up the last d...

Page 55: ...count element containing the number of repeating elements to follow If the Coordination of Benefits Other Payments Count has a value of 2 the next four elements cycle twice Segments l The segment separator is always hex 1E l The first segment in a batch is always the 00 Header segment which is fixed length without delimiters It serves the same function as X12 s ISA l The GIT segment that you see i...

Page 56: ...fixed length required fields with no delimiters and ends with hex 03 Example element IDs shown below Detail Segments The G1 record starts with hex 02 followed by the segment ID G1 and then fixed length undelimited fields in the Request Header Segment or Response Header Segment It ends with a hex 03 The G1 record contains the application segments These always start with the Segment Separator charac...

Page 57: ...tch with three G1 segments each with one claim Sample batch with three G1s 1 Batches always start with a 00 Transaction Set Header record The control number is in bold 2 The T is the transmission type and indicates that the batch contains transactions requests rather than responses 3 Start of the first G1 record Notice the B1 indicating that these will be Billing ...

Page 58: ...s This is underlined in the example Each segment ends with a segment terminator hex 1E which displays as a hyphen in this example 2 The mandatory 04 segment is next Like all detail segments it is preceded with AM Trailing spaces are optional and are shown in this example Each element including each segment tag begins with a hex 1C These display as boxes in the example above 3 The conditional 01 se...

Page 59: ...he NCPDP response file that has no 1 1 enveloping A response Trailer NCPDP End of the EDI file that has no 1 1 enveloping Either transmission or response The data can have only one transmission or set and cannot have extraneous characters like end of files or padding after the last element To determine whether your data is a transmission or response look at the first few characters Transmission If...

Page 60: ...pport You can contact TIBCO Support in the following ways l For accessing the Support Knowledge Base and getting personalized content about products you are interested in visit the TIBCO Support website l For creating a Support case you must have a valid maintenance or support contract with TIBCO You also need a user name and password to log in to TIBCO Support website If you do not have a user na...

Page 61: ...ternational copyright laws and treaties No part of this document may be reproduced in any form without the written authorization of TIBCO Software Inc TIBCO the TIBCO logo the TIBCO O logo HIPAA Validator BusinessConnect Community Manager EDISIM Instream Studio and Transaction Insight are either registered trademarks or trademarks of TIBCO Software Inc in the United States and or other countries J...

Page 62: ...PROVEMENTS AND OR CHANGES IN THE PRODUCT S AND OR THE PROGRAM S DESCRIBED IN THIS DOCUMENT AT ANY TIME THE CONTENTS OF THIS DOCUMENT MAY BE MODIFIED AND OR QUALIFIED DIRECTLY OR INDIRECTLY BY OTHER DOCUMENTATION WHICH ACCOMPANIES THIS SOFTWARE INCLUDING BUT NOT LIMITED TO ANY RELEASE NOTES AND READ ME FILES This and other products of TIBCO Software Inc may be covered by registered patents Please r...

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