TIBCO Foresight Products HIPAA and Other Healthcare Related Guidelines List

Transcription

1 TIBCO Foresight Products HIPAA and Other Healthcare Related Guidelines List August 2017 Two-second advantage

2 Important Information SOME TIBCO SOFTWARE EMBEDS OR BUNDLES OTHER TIBCO SOFTWARE. USE OF SUCH EMBEDDED OR BUNDLED TIBCO SOFTWARE IS SOLELY TO ENABLE THE FUNCTIONALITY (OR PROVIDE LIMITED ADD-ON FUNCTIONALITY) OF THE LICENSED TIBCO SOFTWARE. THE EMBEDDED OR BUNDLED SOFTWARE IS NOT LICENSED TO BE USED OR ACCESSED BY ANY OTHER TIBCO SOFTWARE OR FOR ANY OTHER PURPOSE. USE OF TIBCO SOFTWARE AND THIS DOCUMENT IS SUBJECT TO THE TERMS AND CONDITIONS OF A LICENSE AGREEMENT FOUND IN EITHER A SEPARATELY EXECUTED SOFTWARE LICENSE AGREEMENT, OR, IF THERE IS NO SUCH SEPARATE AGREEMENT, THE CLICKWRAP END USER LICENSE AGREEMENT WHICH IS DISPLAYED DURING DOWNLOAD OR INSTALLATION OF THE SOFTWARE (AND WHICH IS DUPLICATED IN THE LICENSE FILE) OR IF THERE IS NO SUCH SOFTWARE LICENSE AGREEMENT OR CLICKWRAP END USER LICENSE AGREEMENT, THE LICENSE(S) LOCATED IN THE LICENSE FILE(S) OF THE SOFTWARE. USE OF THIS DOCUMENT IS SUBJECT TO THOSE TERMS AND CONDITIONS, AND YOUR USE HEREOF SHALL CONSTITUTE ACCEPTANCE OF AND AN AGREEMENT TO BE BOUND BY THE SAME. This document contains confidential information that is subject to U.S. and international copyright laws and treaties. No part of this document may be reproduced in any form without the written authorization of TIBCO Software Inc. TIBCO, Two-Second Advantage, TIBCO Foresight Community Manager, TIBCO Foresight EDISIM, TIBCO Foresight HIPAA Validator Desktop, TIBCO Foresight, and TIBCO Foresight Translator are either registered trademarks or trademarks of TIBCO Software Inc. in the United States and/or other countries. Enterprise Java Beans (EJB), Java Platform Enterprise Edition (Java EE), Java 2 Platform Enterprise Edition (J2EE), and all Java-based trademarks and logos are trademarks or registered trademarks of Oracle Corporation in the U.S. and other countries. The United States Postal Service holds the copyright in the USPS City State Zip Codes. (c) United States Postal Service All other product and company names and marks mentioned in this document are the property of their respective owners and are mentioned for identification purposes only. THIS SOFTWARE MAY BE AVAILABLE ON MULTIPLE OPERATING SYSTEMS. HOWEVER, NOT ALL OPERATING SYSTEM PLATFORMS FOR A SPECIFIC SOFTWARE VERSION ARE RELEASED AT THE SAME TIME. SEE THE README FILE FOR THE AVAILABILITY OF THIS SOFTWARE VERSION ON A SPECIFIC OPERATING SYSTEM PLATFORM. THIS DOCUMENT IS PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, OR NON-INFRINGEMENT. THIS DOCUMENT COULD INCLUDE TECHNICAL INACCURACIES OR TYPOGRAPHICAL ERRORS. CHANGES ARE PERIODICALLY ADDED TO THE INFORMATION HEREIN; THESE CHANGES WILL BE INCORPORATED IN NEW EDITIONS OF THIS DOCUMENT. TIBCO SOFTWARE INC. MAY MAKE IMPROVEMENTS AND/OR CHANGES IN THE PRODUCT(S) AND/OR THE PROGRAM(S) DESCRIBED IN THIS DOCUMENT AT ANY TIME. THE CONTENTS OF THIS DOCUMENT MAY BE MODIFIED AND/OR QUALIFIED, DIRECTLY OR INDIRECTLY, BY OTHER DOCUMENTATION WHICH ACCOMPANIES THIS SOFTWARE, INCLUDING BUT NOT LIMITED TO ANY RELEASE NOTES AND "READ ME" FILES. Copyright TIBCO Software Inc. ALL RIGHTS RESERVED. TIBCO Software Inc. Confidential Information General Contact Information TIBCO Software Inc Hillview Avenue Palo Alto, CA USA Tel: Fax: Technical Support support@tibco.com Web: (Note: Entry to this site requires a username and password. If you do not have one, you can request one. You must have a valid maintenance or support contract to use this site.)

3 Contents HIPAA and Other Healthcare Related Guidelines List... 3 Table 1 - X Table 2 - X Table 4 - X June 2010 Errata... 6 Table 5 - Healthcare Guidelines Non-HIPAA Mandated... 8 Table 6 Healthcare Guidelines for TIBCO Foresight Community Manager... 9 HIPAA and Other Healthcare Related Guidelines Page 1

4 HIPAA and Other Healthcare Related Guidelines Page 2

5 HIPAA and Other Healthcare Related Guidelines List This document lists guidelines provided with the following TIBCO Foresight products: TIBCO Foresight EDISIM, TIBCO Foresight HIPAA Validator Desktop, and TIBCO Foresight. They include X , X , X Errata, Public Companion Guides, and other Healthcare related guidelines. Notes 1. X supported, however changes are no longer being incorporated into these guidelines. 2. X before June 2010 Errata supported, however these guidelines are no longer shipped with TIBCO Foresight products. HIPAA and Other Healthcare Related Guidelines Page 3

6 Table 1 - X Document Name 270 Eligibility, Coverage or Benefit Inquiry 271 Eligibility, Coverage or Benefit Information 276 Health Care Claim Status Request 277 Health Care Claim Status Notification 277 Health Care Claim Status Notification - unsolicited 278 Health Care Services Review Information Request for Review 278 Health Care Services Review Information Response to Request for Review 820 Payment Order / Remittance Advice 834 Benefit Enrollment and Maintenance 835 Health Care Claim Payment/Advice 837 Health Care Claim: Professional EDISIM Non-Addenda EDISIM Addenda No SVALU Records Version X HIPAA Validator Non-Addenda HIPAA Validator Addenda No SVALU Recs GuidelinePlus only Addenda SVALU Recs (PDSA)/ (PDSX) 270-A AA B41A270 PDSA270 PDSX A AA B41A271 PDSA271 PDSX A AA B41A276 PDSA276 PDSX A AA B41A277 PDSA277 PDSX U-AA120 n/a PDSX277U 278-A AREQ RQ 41A278RQ PDA278RQ PDX278RQ 278-A ARES RP 41A278RP PDA278RP PDX278RP 820-A AA B41A820 PDSA820 PDSX A AA B41A834 PDSA834 PDSX W AW B41A835 PDSA835 PDSX Q AQ P B41A837P (*CCI) PDSA837P (*CCI) PDSX837P 837 Health Care Claim: Dental 837-Q AQ D B41A837D PDSA837D PDSX837D 837 Health Care Claim: Institutional 997 Functional Acknowledgement 837-Q AQ I B41A837I PDSA837I PDSX837I n/a n/a n/a n/a PDSA PDF ( X092.pdf X092.pdf X093.pdf X093.pdf X094.pdf X094.pdf X061.pdf X095.pdf X091.pdf X098.pdf X097.pdf X096.pdf Value in GS08 (A1 at end = Addenda) X X092A X X092A X X093A X X093A X X093A X X094A X X094A X X061A X X095A X X091A X X098A X X097A X X096A1 Notes BHT02=13 BHT02=11 Uses SV1 segment Uses SV3 segment Uses SV2 segment Generic X (no HIPAA rules), although PDSA997 does generate structure records in InStream DTL file. HIPAA and Other Healthcare Related Guidelines Page 4

7 Table 2 - X Version X Document Name EDISIM Non-Addenda HIPAA Validator Addenda No SVALU Records GuidelinePlus only Addenda SVALU Records PDF ( Value in GS08 Notes 275 Additional Information to Support a Health Care Claim or Encounter 277 Health Care Claim Request for Additional Information / 275-X n/a 275-X151.pdf X X n/a 277-X150.pdf X151 HIPAA and Other Healthcare Related Guidelines Page 5

8 Document Name EDISIM ** Table 4 - X June 2010 Errata HIPAA Validator * X June 2010 Errata HIPAA Validator No SVALU Records GuidelinePlus only DS, RG, TI 270 Eligibility, Coverage or Benefit Inquiry 270-X X X279 PDSA X279 PDSX X Eligibility, Coverage or Benefit Information 271-X X X279 PDSA X279 PDSX X Health Care Claim Status Request 276-X X X212 PDSA X212 PDSX X Health Care Claim Status Request Medicare n/a 5010-MEDICARE- 276X212 PDSA5010MEDICARE- 276X Health Care Claim Status Response 277-X X X212 PDSA X212 PDSX X Health Care Claim Status Response Unsolicited 277U-X U-X212 n/a n/a PDSX UX Health Care Claim Acknowledgement 277CA-X CA-X CAX214 PDSA CAX214 PDSX CAX Health Care Claim Status Response- Medicare 278 Health Care Services Request for Review 278 Health Care Services Response to Review 820 Payroll Deducted and Other Group Premium Payment for Insurance Products n/a 824 Application Advice 824-X X186A MEDICARE- 277X212 PDSA5010MEDICARE- 277X212.std 278X217Q 278X217Q X217Q PDSA X217Q PDSX X217Q 278X217R 278X217R X217R PDSA X217R PDSX X217R 820-X X PDSA PDSX X X186A1 PDF ( x203_270_271.pdf x203_270_271.pdf 276-X pdf Value in GS X279A X279A X212 HIPAA and Other Healthcare Related Guidelines Page 6 none 277-X pdf X214_277CA.pdf none 278X217Q pdf X X X X X X X217R-5010.pdf X x pdf n/a n/a 824-x pdf 824-x186A pdf 834 Benefit Enrollment and Maintenance 834-X X PDSA PDSX Health Care Claim Payment/Advice 835-X X PDSA PDSX D Health Care Claims Dental 837-X X D PDSA D PDSX D 837I Health Care Claim Institutional 837-X X I PDSA I PDSX I 834-x pdf 835-X pdf 837-x pdf 837-x pdf X X X186A X220A X221A1 Notes BHT02=01, 13, or 36 BHT02= X224A2 Uses SV1 segment X223A2 Uses SV3 segment

9 Document Name 837I Health Care Claim Institutional Medicare A EDISIM ** HIPAA Validator * X June 2010 Errata HIPAA Validator No SVALU Records n/a n/a MEDICAREA GuidelinePlus only DS, RG, TI 837P Health Care Claim Professional 837-X X P (*CCI) PDSA P (*CCI) PDSX P PDF ( Value in GS08 Notes PDSA5010MEDICAREA none X223A2 Uses SV2 segment 837-x pdf X222A1 837P Health Care Claim Professional Medicare B n/a n/a MEDICAREB (*CCI) PDSA5010MEDICAREB (*CCI) none X222A1 HIPAA and Other Healthcare Related Guidelines Page 7

10 Table 5 - Healthcare Guidelines Non-HIPAA Mandated Document Name 275 Health Care Claim or Encounter 275 Health Care Services Review 277 Health Care Claim Pending Status Information 277 Health Care Claim Request for Additional Information (277) 277 Health Care Claim Request for Additional Information 278 Health Care Services Review Information - Inquiry 278 Health Care Services Review Information - Response 278 Health Care Services Review Information - Acknowledgement 278 Health Care Services Review Information - Notification 820 Health Insurance Exchange: Related Payment 820 Health Insurance Exchange: Related Payment (CMS Companion Guideline) EDISIM ** HIPAA Validator * HIPAA Validator No SVALU Records GuidelinePlus only DS, RG, TI 275-X X X314 PDSA X314 PDSX X X X X316 PDSA X316 PDSX X316 PDF ( 275-X pdf 275-X pdf Value in GS X X X X228 n/a PDSX X X pdf X X X213 n/a PDSX X X pdf X X X X313 PDSA X313 PDSX X X215I 278X215I X215I PDSA X215I PDSX X215I 278X215R 278X215R X215R PDSA X215R PDSX X215R 278X216A 278X216A X216A PDSA X216A PDSX X216A 278X216N 278X216N X216N PDSA X216N PDSX X216N 820-X X X306 PDSA X306 PDSX X X pdf 278-X215I-5010.pdf 278-X215R-5010.pdf 278-X216A-5010.pdf 278-X216N-5010.pdf 820-x pdf X X X X X X306 n/a 820-X HIX-820X306 PDSA5010HIX-820X306 No PDF X306 HIPAA and Other Healthcare Related Guidelines Page 8

11 Document Name 834 Benefit Enrollment And Maintenance: Health Care Exchange (CMS Companion Guideline) 834 Health Insurance Exchange: Enrollment 837D 837I 837P Dental, Post-Adjudication Claims Data Reporting Institutional, Post- Adjudication Claims Data Reporting Professional, Post- Adjudication Claims Data Reporting 997 Functional Acknowledgment 999 Implementation Acknowledgment EDISIM ** HIPAA Validator * n/a 834-X HIX- 834X220 HIPAA Validator No SVALU Records GuidelinePlus only DS, RG, TI PDSA5010HIX- 834X X X X307 PDSA X307 PDSX X X X X300 PDSA X300 PDSX X X X X299 PDSA X299 PDSX X X X X298 PDSA X298 PDSX X n/a n/a PDSX X X X231 PDSA X231 PDSX X231 PDF ( No PDF 834-x pdf 837-x pdf 837-x pdf 837-x pdf Value in GS X220A X X X X298 No PDF _X231.pdf X231 HIPAA and Other Healthcare Related Guidelines Page 9

12 Table 6 Healthcare Guidelines for TIBCO Foresight Community Manager Guideline Name Purpose Notes FSSD X279 FSSD X279 FSSD X212 FSSD X212 FSSD X217REQ FSSD X217RES FSSD X218 FSSD X220 FSSD X221 FSSD DX224 FSSD IX223 FSSD PX222 FSSD5010-MEDICAREA FSSD5010-MEDICAREB Community Manager only For customers who host their own Community Manager, merge these with your company guidelines to create production guidelines that contain scenarios. Guidelines are installed in s CommunityManagerGuidelines directory. HIPAA and Other Healthcare Related Guidelines Page 10