Mastering HIPAA 5010 EDI Implementation Guides and EZ-EDI Mapping Christian Ulangca (Sr. EDI Analyst) Rini Jose (Product Manager)
What is HIPAA 5010? The 1996 HIPAA legislation required the US Department of Health and Human Services (HHS) to adopt electronic standards for conducting electronic healthcare transactions, to adopt standards for any code values used in the transactions, and to establish privacy and security standards that prevent unauthorized access to private medical information. HHS established the use of the ASC X12 standards for electronic healthcare transactions, and the initial version of these standards was 4010 adopted in August 2000; an update to 4010 known as 4010A1, or "Addenda", was adopted in May 2002. In January 2009, the HIPAA regulations were updated to require version 5010, which attempts to more rigidly define data values and how they are used. Where 4010 focused on structure, 5010 focuses on content. The 5010 update affects all healthcare entities and all HIPAA transactions. 2
ASC X12 HIPAA 5010 Format Developed and maintained by ASC X12 http://www.x12.org/ ASC X12 s exclusive publisher is Washington Publishing Company http://www.wpc-edi.com/ Adopted by HIPAA and mandated to as of 01/01/2012 3
X12 EDI File Structure ASC X12 standards dictates the structure of files. The EDI file structure contains loops, segments, elements and composite elements. Loops contain segments, a segment contains elements and elements may contain other elements (composite elements). 4
5 X12 EDI File Structure
6 X12 EDI Segment Structure
Interchange Header & Trailer (ISA/IEA) ISA Segment ISA01 Authorization Information Qualifier ISA02 Authorization Information ISA03 Security Information Qualifier ISA04 Security Information ISA05 Interchange ID Qualifier ISA06 Interchange Sender ID ISA07 Interchange ID Qualifier ISA08 Interchange Receiver ID ISA09 Interchange Date ISA10 Interchange Time ISA11 Repetition Separator ISA12 Interchange Control Version Number ISA13 Interchange Control Number ISA14 Acknowledgement Requested ISA15 Usage Indicator ISA16 Component Element Separator IEA Segment IEA01 Number of Included Functional Groups IEA02 Interchange Control Number (same as ISA13) 7
GS/GE Group Header & Trailer ST/SE Transaction Set Header & Trailer GS Segment GS01 Functional Group ID code GS02 Application Sender's Code GS03 Application Receiver's Code GS04 Date GS05 Time GS06 Group Control Number GS07 Responsible Agency Code GS08 Version/Rel. Ind. ID Code GE Segment GE01 Number of Transaction Sets Included in this Function Group GE02 Group Control Number (same as GS06) ST Segment ST01 Transaction set ID code ST02 Transaction set control number SE Segment SE01 Number of included segments SE02 Transaction set control number (same as ST02) 8
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Industry usage The three choices for Usage are required, not used, and situational. To avoid confusion, these are named differently than the X12 standard Condition Designators (mandatory, optional, and relational). Required This loop/segment/element must always be sent. Required segments in Situational loops only occur when the loop is used. Required elements in Situational segments only occur when the segment is used. Required component elements in Situational composite elements only occur when the composite element is used. Not Used This element must never be sent. Situational Use of this loop/segment/element varies, depending on data content and business context as described in the defining rule. The defining rule is documented in a Situational Rule attached to the item. 10
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5010 Standard Acknowledgements TA1 Interchange Acknowledgment TA1 provides the capability for the interchange receiver to notify the sender that a valid envelope was received or that problems were encountered with the interchange control structure. The TA1 verifies the envelopes only. 999 Implementation Acknowledgment The 999 informs the submitter that the functional group arrived at the destination. It may include information about the syntactical quality of the functional group and the implementation guide compliance. 277 Health Care Claim Acknowledgment The 277 provides an application level acknowledgment of electronic claims. It may include information about the business validity and acceptability of the claims. 16
TR3 Guides Search for an element Browse to the Table of Contents page Locate Segment Name Click on Page number 17
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19 Service line balancing
X12 Raw Data EDI X12 file can be either continuous stream of data or each segment in a separate line. Each element, composite element and segment in an EDI X12 files are separated by the delimiters. 20
21 EZ-EDI Map Editor
Map Editor Data Elements : Source Data Elements listed on Left Hand Side (LHS) Destination Data Elements listed on Right Hand Side (RHS) Inbound Map (Source 837 File, Destination EZ-CAP) Outbound Map (Source EZ-CAP, Destination 837 File) 22
Fields grouped into different levels Data is packaged into multi level structure, representing the different Hierarchical levels in 837. Mapping from a Parent loop to a child loop is allowed, but not vice versa. (Mapping from a higher loop (smaller number of loop label) to a lower loop (higher number on label) is allowed and NOT the opposite) 23
Mapped Elements Click on any Mapped Element on either side displays the existing mappings Mapped Elements section displays all current mappings sorted in alphabetical order 24
Drag & Drop Mapping Drag Field from Left (Source) to the selected Right Field (Destination) 25
Multisource Mapping Mapping can be done Many to One or One to Many Remove one or many sources using Right Click -> View Sources 26
27 Set Priority vs. Concatenation
Assign Constant Elements not required in EZ-CAP, but required in 837 or Vice Versa Constant Value assumes lowest priority in mapping 28
Modify Constant Value Icon indicates that Constant Value is assigned to a field. Use Right Click -> Modify Constant to change value 29
Confirm Custom Map Confirm custom map updates any new mappings and moves the fields over to the mapped section. (Font color changes from Pink to Purple) 30
Data Manipulate screen Last used file gets loaded when using data manipulation function. Inoad / Outload small files prior to using data manipulate screens 31
View Output of Custom Map without creating test files Curved Arrow displays Result of Priority Mapping / Data Manipulation / Concatenation Blue Arrow indicates data manipulation rules exists for the specific filed Data Manipulate screens display the output of custom maps Use files including relevant data to view results directly on screen 32
Search Option Ctrl + F to search the destination fields in data manipulation Destination Field in Bold Autocomplete suggestions to type the destination field names. 33
Custom Cross Reference Table Create & save CCR tables to be used in Custom Maps 34
Scrub Source Data Rules applied on Source of Data If the source is mapped to multiple destination fields, data scrub affects all mappings 35
Cross Reference Used for building Cross reference table for current map 36
Situational Cross Reference Data in a source field altered based on another source field 37