HIPAA Implementation Guides Down and Dirty: Who Needs To Understand Them?
HIPAA Implementation Guides Down and Dirty: Who Needs To Understand Them?
HIPAA Implementation Guides Down and Dirty: Who Needs To Understand Them?
SERVICE
CLAIMS
CLAIMS
PROCESSING
ALLIANCE
DETROIT MI
CUST
ENROLLMENT SERVICE
PAPER vs EDI
Document - Transaction
Little Envelope- Functional Group
Big Envelope - Interchange
Postal Service - VAN
Courier Delivery- Point-to-Point
Human Audit - Machine Audit
EDI Delivery
270 FUNCTIONAL
GROUP INTERCHANGE EDI
VAN
837 FUNCTIONAL
GROUP
INTERCHANGE
834 FUNCTIONAL
GROUP
Standards Language
Document - Transaction
Line - Segment
Phrase - Composite Element
Word - Simple Element
Code - Identifier
Punctuation - Delimiters
Grammar - Syntax
SIMPLE AND COMPOSITE
DATA ELEMENTS
N1*PR*ABC INS CO*PI*ABC47~
TOO*JP*8*F:L~
Levels of Standards Documentation
ANSI X12 Standards Documentation
Industry Implementation Guidelines
Trading Partner Profiles
Section I - Transaction Set Tables
Table 1 ST
Header BHT
Related information
Table 2 HL
usually appears
Detail together.
Table 3
Summary SE
837 Health Care Claim Functional Group ID: HC
Table 1 Header
POS# SEG ID NAME REQ. DES MAX USE LOOP REPEAT
005 ST Transaction Set Header M 1
010 BHT Beginning of Hierarchical Transaction M 1
LOOP ID 1000 10
020 NM1 Individual or Organization Name O 1
045 PER Administration Communication Contact O 2
Table 2 Detail
POS# SEG ID NAME REQ. DES MAX USE LOOP REPEAT
LOOP ID 2000 >1
001 HL Hierarchical Level M 1
003 PRV Provider Information O 1
LOOP ID 2010 10
015 NM1 Individual or Organization Name O 1
040 PER Administration Communication Contact O 2
Permitted segments
Required order
Presence requirement
How many
Loops
RECEIVER NAME
NM1 Individual or Organization Name
Level: Header
Syntax: 1. P0809
If either NM108 or NM109 is present, then the other is required.
N1
* * ~
Data Element Dictionary
Listed numerically
Same in all segments
Data & position vary
Length min & max
Code lists
Type of data
HL Hierarchical Level
HL01 628 HL02 734 HL03 735 HL04 736
Hierarch Hierarch Hierarch Hierarch
HL * ID Number
M AN 1/12
* Parent ID
O AN 1/12
* Level Code
M ID 1/2
* Child Code
O ID 1/1
~
HL01 628 Hierarchical ID Number
The first HL01=1, in subsequent HL segments the value is
incremented by 1.
HL02 734 Hierarchical Parent Number
The HL02 identifies the HL01 that is the parent of this HL
segment.
HL03 735 Hierarchical Level Code
20 = Billing Provider
22 = Subscriber Child to Billing Provider
23 = Dependent Child to Subscriber
HL04 736 Hierarchical Child Code
0 No Subordinate HL Segment
1 Additional Subordinate HL Data Segment
Hierarchical Levels in Health Care Claims
HL*1**20*1~
Billing Provider
Simplify data.
INVOICE
Eliminate transactions.
Utilize status information rather than batch data.
Reengineer business processes.
Exchange information more frequently.
Session Summary