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Posts Tagged "HIPAA"

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…

Rapid EDI Trading Partner Onboarding with T-Connect

HIPAA X12 EDI transmission between the many entities in the HealthCare industry is performed using files conforming to ANSI X12 specifications. These Claim, Premium Payment and Remittance Advice EDI files may originate from payers, providers, clearinghouses, or third party administrators (TPAs). One prevalent hurdle in sending or receiving these EDI transactions is the often complex onboarding process of new trading partners.
HIPAA EDI files in X12 format may typically look similar to the sample below.

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…

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…

All-Payer Claims Database Submission – Common Data Layout and PACDR X12

As we strike out into 2018, the implementation of All-Payer Claims Databases (APCD) across states remains variable and dynamic. Massachusetts maintains a comprehensive implementation, aggregating data feeds from over 80 public and private payers.  Massachusetts has leveraged their APCD to create a state-specific risk adjustment model to meet the ACA provision which balances funds from healthier populations to higher risk pools. Late in 2016, Minnesota concluded a feasibility study which determined their APCD could significantly improve risk adjustment vs. the federal model.
On the other hand, West Virginia and Tennessee have put APCD development on hold. California payers optionally submit claims and encounters to a public benefit corporation. Legal, fiscal and political concerns guarantee a fluid situation for insurers.
This blog post is focused on the technical obstacles that health plans face in states requiring APCD submission. Since these databases have phased in over the last decade through both voluntary and legislated…

X12 EDI Databases for HIPAA Transactions

The X12 HIPAA transaction set is used across the healthcare industry to transmit claim, enrollment and payment information. Given the importance and ubiquity of these EDI files, you might assume that translating them from ANSI to a relational database format would be well-supported with a range of options.
In practice, a task as common as parsing a claim or encounter and storing it in a database can quickly escalate into a significant problem.
One solution we’ve seen involves archiving a snapshot of the EDI file using filestream storage. This can satisfy some retention requirements, but provides little in terms of fine-grained tracking or analytic capabilities.
A more complete approach is to parse the X12 file into its discrete elements and store them in a relational database. The ideal solution captures the full extent of the EDI transactions while also applying a reasonable leveling of flattening to keep in the number of table joins under control.
The…

Working with HIPAA Professional Claim (837P) Messages in BizTalk (Part2)

In the last post, I wrote about the overall structure of 837P claim messages.  837I and 837D messages have similar structures, though with some differences – for example, the 837I has many more diagnosis code options, and the 837D has more specific nodes for tooth identification, etc.  One important thing to note is that 837P, 837I, and 837D files are very similar, but not the same.  It’s not enough to simply change the version numbers in the GS and ST segments and then try to process one the same as the other!  If it were that easy, we wouldn’t need separate schemas for them in BizTalk!
BizTalk provides out of the box functionality to support these message types, with well developed functionality to translate the X12 EDI to XML and vice versa.  The schema nodes also have friendly names, translating something like this:
NM1*IL*1*Field*Dan****MI*123456789~
To…

Working with HIPAA Professional Claim (837P) messages in BizTalk (Part 1)

Updated: part 2
Application integration is challenging in that it requires a wide breadth of knowledge: server and network architecture, object oriented programming and design patterns, messaging and communication patterns, workflow design, message translation, database design and programming, business rule processing, data validation and quality handling… the list goes on and on.  On top of that, it’s important to be familiar with the data you’re working with from various sources and feeds to be able to effectively transform it.
EDI presents a whole host of challenges, and the 837 Professional, Institutional, and Dental transactions are among the most challenging to grapple with.  This will be the first in a series covering a high level introduction and overview of the 837 Claim format in the BizTalk HIPAA EDI schemas.  It is not quite going to the level of a competent EDI Analyst, but…

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