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Category Archive for "Healthcare"

SNIP 6 – Line of Service or Product

What are HIPAA SNIP types? We get this question a lot, so we’ve been blogging about the different categories WEDI has defined to validate healthcare EDI transactions. Thus far, we’ve covered:

SNIP 1 & 2 Integrity and Requirement Testing
SNIP 3 Claim Balancing
SNIP 3 Remittance Advice Balancing
SNIP 4 Intersegment Situational Testing
SNIP 5 External Code Set Testing

These rules are sometimes referred to as SNIP levels – although that may wrongly imply that each type builds upon the previous category. In actuality, each SNIP type is a standalone set of validations rules.
In this article, we’ll focus on SNIP 6.
Type 6
SNIP 6 enforces situational rules specific to service lines and products. While SNIP 4 also focuses on situational rules that analyze the relationships between loops, segments and elements, SNIP 6 differs in that the rules apply to subsets within the transaction sets.
For example, within an 837…

SNIP 4 – EDI Intersegment Situational Rules

WEDI SNIP Types define sets of rules for validating EDI transactions such as 837 claims, 834 enrollments or 835 Remittance Advice.
Previously, we’ve blogged about:

SNIP 1 & 2 Integrity and Requirement Testing
SNIP 3 Claim Balancing
SNIP 3 Remittance Advice Balancing
SNIP 5 External Code Set Testing

This article focus on SNIP 4, which test situational rules spanning separate loops, segments, or elements. What differentiates these rules from Type 2 is that the situational tests span distinct segments, while Type 2 is considered intrasegment testing. Intrasegment tests validate the presence of elements within the same segment based on syntax rules.
Type 4
SNIP 4 situational rules break into two categories. Both categories consist of a condition statement, then a data item (loop, segment, or element) which should (or should not) be present based on the rule evaluation.
Category 1
The first category of situational rules specifies that sending the specified data item is up…

SNIP 5 – HIPAA External Code Set Testing

The HIPAA X12 EDI specification allows for the inclusion of code values that may be pertinent to the transaction set, such as a claim or encounter. These code values can represent a data point as widespread as a postal or zip code, or as complex as diagnosis and procedure codes.
WEDI describes seven types of validation, referred to as SNIP 1-7, as covered in some of our previous blog posts on SNIP 3 Balancing of Claims and Payments. SNIP 5 – HIPAA External Code Set Testing is the validation of code values against the external code sets they represent.
SNIP 5
As previously stated, SNIP 5 validates that code value exists within an external code list. For example, if a postal (zip) code is present in a subscriber’s address, then it should align with an actual postal code in as determined by the USPS, the…

Submitting Workers Compensation Claims as 837s

Workers compensation claims contain a special set of requirements when submitted in the EDI 837 format. This article describes these specific characteristics.

In a standard 837, the 2000B loop always contains subscriber information (the primary insured individual). Claim level information (2300 loop) is nested beneath the 2000B loop in this scenario. The 2000C (Patient) loop is present in the case in which the claim is related to a dependent of the subscriber. In these cases, the 2300 loop is nested under 2000C. In workers comp claims, a 2000B and 2000C loop always exist, and their purposes are a bit different. Information related to the employer goes into the 2000B loop, while the 2000C loop is used for the claimant (the injured worker). The concept of a dependent doesn’t exist in workers comp claims.

The SBR segment present in 2000B is a required…

CAQH CORE Certification Tips

CAQH CORE certification demonstrates that health plans, clearinghouses and software vendors meet federally mandated operating rules when exchanging HIPAA EDI transactions. Internally for organizations, the certification process provides value by exercising a broad variety of test cases. Last but not least, CORE specifies the message envelope details for exchanging EDI over two types of HTTP endpoints, reducing the implementation times that custom message formats can incur.
The CAQH website is the complete resource for understanding the types and variations of CORE certification. In this article, we’ll take a complementary approach. Rather than attempt to summarize the full spectrum of options, we’ll focus on a single use case in order to highlight key information and technical challenges. Tallan’s T-Connect Eligibility Module places us in the software vendor category. Our EDI management solution enables health plans to act as an information source to respond to 270 Eligibility requests with a…

Tracking and Fixing Encounters, Enrollments and other EDI with T-Connect

There are several ways to intake, parse and route encounters, enrollments, payments and other HIPAA X12 EDI files. However, there are often deficiencies that become quickly apparent, as not many systems provide an adequate level of insight into the status of the in-flight files, nor do they have the tools needed to respond to issues once they arise.

TriZetto QNXT – EDI Reporting and Tracking

Each day health plan administrators look forward to the challenge of loading 834 enrollments and 837 claims into their adjudication systems.
From a distance, it seems simple to report and reconcile the EDI transactions submitted by providers and clearinghouses through a plan’s intake workflow. Drilling into the steps along the inbounding process, challenges emerge which can present insurmountable obstacles to answering a question as basic as: How long has this claim been held up in my intake process?
TriZetto QNXT is a common adjudication platform we’ll use to illustrate this point. In a typical workflow, loading claims might involve:
Handoff: The day’s 837s are pulled from an SFTP server and moved to the start of the intake process.
Archive: Move files into processing workflow, and archive a copy.
EDI Structural Validation – Basic checks are performed to ensure the 837 transactions are well-formed. This level of validation is…

Notes from the 2018 WEDI Spring Conference

This year’s WEDI Spring Conference mixed deep dives into emerging X12 standards with sessions centered on Open APIs and a greater unification of clinical and administrative data. Here are a few of the topics that jumped out at me, with some thoughts on what these trends might mean for T-Connect customers.
FHIR – The maturing FHIR standards arguably represent the most dynamic developments in HIT at present. FHIR (Fast Healthcare Interoperability Resources) is set of specifications developed by HL7 that most immediately concerns clinical data in EHR systems, but also extends to the exchange and content of administrative transactions, such as claims and eligibility requests.
FHIR is an implementation of modern web standards present in most other industries:

RESTful APIs
XML and JSON messages
OAuth 2.0 as the security mechanism

FHIR also defines resources which represent discrete data elements. Here’s a partial view of a FHIR claim resource:
It’s important to note that these standards are…

A HIX 820 Overview

When the Health Insurance Exchange (HIX) network went online in late 2013, the industry was challenged with reconciling new subscribers to their related premium payments and subsidies. Health plans painstakingly assembled Excel eligibility extracts to invoice their Federally Facilitated Marketplace (FFM) or State-based Exchange (SBE) for tax credit reimbursement. However, by the start of 2016, the FFM became the system of record for eligibility, and issuers were required to accept a new variant of EDI representing premium payments.
Traditionally, the 820-Payment Order / Remittance Advice transaction (005010X218) has been transmitted from payroll agencies and government healthcare organizations to insurers in order to provide summary or subscriber-level information regarding premium payments. With the advent of ACA exchanges, enough variations surfaced in this traditional handshake that a new version of the 820 was required. The HIX 820 (005010X306) removes structures unnecessary for exchange reporting, and adds tracking segments for the unique aspects of these plans, such as…

Claim Balancing – SNIP 3 for 837s and Post-Adjudicated Encounters

Ensuring that 837 EDI transactions meet validity checks is critical to improving auto-adjudication and encounter submission acceptance rates. SNIP Type 3 describes the rules for balancing header and detail levels of the Claim, Premium Payment and Remittance Advice transaction sets. Previously, our blog covered the logic required to balance 835 transactions. Now we’ll look at the steps necessary to balance claims with service lines, including Coordination of Benefits loops in multiple payer scenarios.
Claims and encounters may be represented by a variety of X12 transaction types: 837 Professional, Institutional and Dental, as well as their corresponding post-adjudicated variants (298, 299, 300), intended for submission to All-Payer Claims Databases. The following logic applies to all versions of the 837 equally, with a few caveats noted below.
Rule 1 – Balancing Claim Charge Amounts
The first claim balancing rule is straightforward: given the parent-child relationship of 2300 claim loops to their 2400 service…

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