EDIFECS Content EDIFECS Standards – HIPAA Database

EDIFECS®
Standards - HIPAA Database 8.0.9
Release Notes
Content
Standards
Changes
Installation
EDIFECS Standards – HIPAA Database
EDIFECS Standards Database: EDI - HIPAA
This setup program includes the following versions of HIPAA standard:
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HIPAA - V4010 (issue of May 2000)
HIPAA - V4010A1 (issue of October 2002) with business rules
HIPAA - V5010 (some transactions with Errata) with business rules*:
HIPAA - V5010A (transactions with Errata A1 and A2, issue of August 2010) with business rules:
o 270/271, 005010X279A1: Health Care Eligibility Benefit Inquiry and Response
o 276/277, 005010X212: Health Care Claim Status Request and Response
o 278/278, 005010x217: Health Care Services Review - Request for Review and Response
o 820, 005010x218: Payment Order / Remittance Advice
o 834, 005010X220A1: Benefit Enrollment and Maintenance
o 835, 005010X221A1: Health Care Claim Payment/Advice
o 837 Professional, 005010X222A1: Health Care Claim: Professional
o 837 Institutional, 005010X223A2: Health Care Claim: Institutional
o 837 Dental, 005010X224A2: Health Care Claim: Dental
*Note: updates to version V5010 are frozen starting from release 7.0.19. Support of this version is discontinued.
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EDIFECS Standards Database: External Code Lists for HIPAA
This setup program includes the following HIPAA external code lists:
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4 - ABA Routing Number
5 - Countries - ISO 3166, Currencies and Funds - ISO 4217, Country Subdivision - ISO 3166
16 - D-U-N-S Number
22 - States and Outlying Areas of the U.S.
41 - Universal Product Code
43 - FIPS-55
51 - ZIP Code
60 - DFI Identification Number
73 - Drug Enforcement Administration
77 - X12.3 Data Element Dictionary/X12.22 Segment Directory
91 - Canadian Financial Institution Branch and Institution Number
94 - International Organization for Standardization (Date and Time)
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102 - Languages
121 - Health Industry Identification Number
130 - HCPCS
131 - ICD-9-CM
132 - National Uniform Billing Committee (NUBC) Codes
132 - NUBC Condition Codes
132 - NUBC Occurrence Codes
132 - NUBC Occurrence Span Codes
132 - NUBC Revenue Codes
132 - NUBC Value Codes
133 - CPT® Codes (CPT copyright 2011 American Medical Association. All rights reserved.)
134 - National Drug Code
135 - American Dental Association Codes (CDT-3; CDT-4, CDT-5)
135 - ADA Oral Cavity Designation Codes
135 - ADA Universal/National Tooth Numbering System
139 - Claim Adjustment Reason Codes
145 - County Designator Code
158 - Health Care Financing Administration (HCFA) - Code Lists
161 - Academic Degree Code
229 - Diagnosis Related Group Number (DRG)
230 - Admission Source Code
231 - Admission Type Code
235 - Claim Frequency code
236 - NUBC Facility Type Code (2 digits)
236 - NUBC Bill Type Code
237 - Place of Service
239 - Patient Status Code
240 - National Drug Code by Format
245 - National Association of Insurance Commissioners (NAIC) Code
284 - Nature of Injury Code
307 - National Association of Boards of Pharmacy Number
359 - Treatment Codes
407 - Occupational Injury and Illness Classification Manual (Nature of Injury Codes)
411 - Remittance Remark Codes
457 - NISO Z39.53 Language Code List
507 - Health Care Claim Status Category Code
508 - Health Care Claim Status Code
513 - Home Infusion EDI Coalition (HEIC) Code List
522 - Health Industry Labeler Identification Code
530 - National Council for Prescription Drug Programs Reject/Payment Codes
537 - Health Care Financing Administration National Provider Identifier
540 - Health Care Financing Administration National PlanID
541 - Social Security Number
582 - Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms
663 - Logical Observation Identifier Names and Codes (LOINC)
682 - Health Care Provider Taxonomy codes
683 - Provider Characteristics and Resources Code
716 - HIPPS Rate Code for Skilled Nursing Facilities
843 - Complimentary Alternative Holistic Procedure Code (ABC Codes)
881 - Version / Release / Industry Identifier Code
844 - Eligibility Category
859 - Classification of Race or Ethnicity
886 - Health Care Decision Reason Code
895 - Insurance Business Process Application Error Codes
896 - International Classification of Diseases, 10th revision, Procedure Coding System (ICD-10-PCS)
897 - International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)
HCFA Public Use Files
Canadian Province Abbreviations
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CLIA Number
IHS/CHS Tribal Residency Codes
Provider Taxonomy Codes
AEC1 - Insurance Business Process Application Error Codes
Health Insurance Prospective Payment System Codes
PQRI - Physician Quality Reporting Initiative Codes
BETOS - BETOS codes
DOD1 - Military Rank and Health Care Services Region
DOD2 - Paygrade
NOC - Not Otherwise Classified codes
POA Exempt Diagnosis Codes
Additional External Code Lists will be available on Edifecs website.
Changes
The minimum supported version of SpecBuilder and XEngine is changed to 6.7.
Folders/Files that were updated
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Files in the folder Edifecs\STANDARDS\HIPAA\V4010A
o 835-W1, 837-Q1, 837-Q2, 837-Q3
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Files in the folder Edifecs\STANDARDS\HIPAA\V5010A
o 270x279A1, 271x279A1, 276x212, 277x212, 278x217-Res, 278x217-Req, 820x218, 834x220A1,
835x221A1, 837x222A1, 837x223A2, 837x224A2
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Files in the folder Edifecs\STANDARDS\Shared\X12N
o JS.jsb, JS.jsc, Template.xml, sbaff.xml, sbaff-6.2.xml, Ackcode277Ax214.xml, Ackcode277Ax2148.0.xml
o Rc-evt\393.xml
o Rc-str\1033\57.xml
Update to the Error Resources
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Updated severity for 0x3938EDC, 0x3938EDD, 0x3938BEF
Updated description for 0x39393D5, 0x393946F, 0x393967D, 0x3938B4D, 0x3938B8A, 0x3938BCE,
0x3938BEF
Updated brief for 0x393967D
Added new events 0x393936F, 0x3939370, 0x3939496 - 0x39394AA, 0x393967F, 0x3939680, 0x3938B8E,
0x3938BF3, 0x3938C8D
Update to the Settings files
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Updated acknowledgment config files - AckCode277Ax214.xml and AckCode277Ax214-8.0.xml.
o Empty code mappings are removed
o Claim Status code 570 mapping is replaced by codes 704 and 586 for errors in 2300\2400 K3 segments
Update to V4010A/V5010A
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All, 5010A - ICD-10 mandated date is changed to 10/01/2014.
All, 5010A - HPID availability date is changed to 11/05/2012. HPID mandated use date is changed to
11/07/2016.
All, 5010A - Added format validation for HPID.
All, 4010A1\5010A - Updated edits for validation of monetary amount (element 782) value format to report an
error only when value is numeric.
All, 5010A - Added user notes for the Transaction node with IG name.
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All, 5010A - Validation of ECL 576 is updated to use appropriate ECL structure.
All, 5010A - Added ability to choose date for validation of NUBC and DRG codes: transaction vs service.
All, 5010A - Validation of ECL 716 is extended to include Home Health and IRF codes.
All, 5010A - Added ability to restrict usage of ICD-9/ICD-10 codes for the same transaction/business unit.
270, 5010A - Removed restriction to use repetition feature for EQ01 when 2110 loops are sent with the same
information.
270\271, 5010A - Added a warning message when secondary diagnosis is a duplicate of the primary diagnosis
code
271, 5010A - To avoid JavaScript system errors for undefined variable ec_2110C when data file has only 2000A
loop, 'ec_b2110C' declaration is added in the System Global Declaration.
271, 5010A - Updated the Situational Rule note for 2000D\TRN.
271, 5010A - Added new edit for segment 2000C\TRN so it used only when the subscriber is the patient.
271, 5010A - Added new edit for loops 2110C/D so they are not used when rejection is reported at higher levels.
271, 5010A - Edit for missing loop 2000D is removed as unclear since similar error is already reported for
missing loop 2110C in such situation.
271, 5010A - Updated edit for minimum data content for eligibility response: EB with EB01 with '1'-'8' and EB03
as ‘30’ is required in at least one instance of loop 2110C/D when patient is found.
278, 5010A - Updated mechanism to select date used for validation of "medical" Diagnosis (ICD-9 and ICD-10)
and Procedure (HCPCS, NDC, ICD-9, ICD-10 and CDT) codes.
278 Request, 5010A - Updated edit for missing BHT06 which is required when BHT02 is '36'.
278 Response, 5010A - Added new edit for Diagnosis date not to be used with LOINC code.
278 Response, 5010A - Removed edit that requires using 'PI' qualifier for UMO primary identifier in
2010A\NM108 when HPID is not mandated.
820, 5010A - Fixed invalid error 0x3938C7F (60001407) reported for incorrectly used loops 2312A and 2320A
when 2300A\RMR05 is 0.
820, 5010A - Fixed edit for missing loop 2320A when 2300A\RMR04 is different from RMR05 and loop 2312A is
not used.
835, 5010A - Enhanced check for missing 2100\DTM "Coverage Expiration Date" not to require its presence on
a reversal of previous payment.
835, 5010A - Updated check to detect zero value for BPR02 when BPR01 is 'H'.
835, 5010A - Updated validation for DRG codes to use ECL 229 for Medicare or when ec_bMedicare229 is set
to true.
835, 5010A - Added new edit for Adjustment Quantity to restrict usage of zero value.
835\All 837s, 5010A - Added an informational message reported for 2100\MOA01 (835) and 2320\MOA01 (837)
when its value is more than 1.
All 837s, 5010A - Changed error severity for COB balancing errors from warning to rejecting error.
All 837s, 4010A1 - Changed error IDs for COB balancing warnings.
All 837s, 5010A - Fixed edit for COB balancing: error was not reported in some situations when 2320\AMT Payer
Paid Amount was sent with zero value and no CAS segments.
All 837s, 5010A - Decreased severity of error for missing 2320\AMT Remaining Patient Liability segment from
Rejecting Error to Warning.
All 837s, 5010A - Edits for incorrectly used segment REF (Payer Claim Control Number) in loop 2300 is
updated.
All 837s, 5010A - Updated list of currency codes to signal US Dollar for 2000A\CUR02 edit.
All 837s, 5010A - Updated edit for the comparison of contact name between loops 1000A, 2010AA, 2310C to
ignore case difference.
All 837s, 5010A - Updated edit for the comparison of contact name between loops 1000A, 2010AA, 2310C.
All 837s, 5010A - Fixed incorrectly reported error for missing 2330B\DTP for prior payers when Total Noncovered Amount is sent.
837P, 5010A - Updated edit to compare if same date is sent in DTP (Date - Onset of Current Illness or
Symptom) and DTP (Date - Service Date).
837P, 5010A - Updated several edits that involve Medicare/Medicaid requirements. Originally only Destination
payer (loop 2000B) was looked at to see if claim is for Medicare/Medicaid, now we look at Other payers (loop
2320) as well.
837P, 5010A - Added new edit for 2310C\NM109: its value cannot be the same as value of 2010AA\NM109.
837P, 5010A - Updated Situational Rule note for 2400\SV101-06.837P, 5010A - Updated check for 2300\CRC Hospice Employee Indicator segment usage which should be used
only for Medicare.
837P, 5010A - Updated edit for 2400\SV103 to recognize anesthesia procedure code as expected value for
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SV103 is 'MJ' for anesthesia claims.
837P, 5010A - Added new edit for 2400\SV5 segment: it should not be used when SV504 is zero.
837P, 5010A - Fixed an edit to report an error for misused ICD10 code depending on an order of service lines.
837I, 5010A - Added new edit to disallow duplicate Patient Reason codes on the same claim.
Specific details about each item are described in HIPAA Readme file.
Installation
The setup is compatible with SpecBuilder 6.7 through 8.0 and XEngine 6.7 through 8.0.
HIPAA Release 8.0.9 requires ECL Release 8.0.8 or higher when used with SpecBuilder or XEngine 6.7 and higher.
Starting Release 7.0.12 the HIPAA Unix setup has new installation instructions and no longer requires Perl or GNU tar:
1) Unzip and untar HIPAAInstEdifecs.tar.gz.
Example:
tar –xzvf HIPAAInstEdifecs.tar.gz
* This command may vary in your environment. Please check with your Unix administrator for more details.
2) You will now see installation scripts for every platform and the archive file HIPAAEcl2.7.0.12.86.tar. Select the
applicable installation script for your specific platform then run it.
Example:
./HIPAAGuidelineInstaller-solaris-x86 <option>
With the following installation options for HIPAA setup:
-n
Activate network based installation, not applicable with "-o" flag
-r <root_path>
Set Edifecs products root folder, not applicable if ECRootPath is already set
-m
Disable system environment update (ECRootPath, Windows registry)
-d <install_path>
Set destination path where the standard will be installed
-s <package_loc> Identify location of the installation package
-null
Suppress NULL redirection in system calls
-l <logfile>
Redirect installation messages to the specified log file
-y
Suppress prompting to overwrite an existing version
-h
Print this help message
-b
Force to retain backup of previous version
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Force 6.1-6.6 releases installation, not applicable with "-o" flag
-f
Disable check-out for free space
-o
Force OLD (pre 6.1) release installation
From Release 7.0.12 the HIPAA Win setup support x32 and x64 systems and has new installation instructions:
1) Run HIPAAInstEdifecs.exe file
2) Run HIPAAGuidelineInstaller-Win32.exe file with following available installation options:
Example:
./HIPAAGuidelineInstaller-Win32 <option>
-n
-r <root_path>
-m
-d <install_path>
-s <package_loc>
-null
Activate network based installation, not applicable with "-o" flag
Set Edifecs products root folder, not applicable if ECRootPath is already set
Disable system environment update (ECRootPath, Windows registry)
Set destination path where the standard will be installed
Identify location of the installation package
Suppress NULL redirection in system calls
-l <logfile>
-y
-h
-b
-66
-f
-o
Redirect installation messages to the specified log file
Suppress prompting to overwrite an existing version
Print this help message
Force to retain backup of previous version
Force 6.1-6.6 releases installation, not applicable with "-o" flag
Disable check-out for free space
Force OLD (pre 6.1) release installation
Copyright Edifecs 2013