TIBCO Foresight Products HIPAA and Other Healthcare Related Guidelines List

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

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Contents HIPAA and Other Healthcare Related Guidelines List... 3 Table 1 - X12-4010... 4 Table 2 - X12-4050... 5 Table 4 - X12-5010 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

HIPAA and Other Healthcare Related Guidelines Page 2

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 X12-4010, X12-4050, X12-5010 Errata, Public Companion Guides, and other Healthcare related guidelines. Notes 1. X12-4010 supported, however changes are no longer being incorporated into these guidelines. 2. X12-5010 before June 2010 Errata supported, however these guidelines are no longer shipped with TIBCO Foresight products. HIPAA and Other Healthcare Related Guidelines Page 3

Table 1 - X12-4010 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 X12-4010 HIPAA Validator Non-Addenda HIPAA Validator Addenda No SVALU Recs GuidelinePlus only Addenda SVALU Recs (PDSA)/ (PDSX) 270-A120 270AA120 4010270 B41A270 PDSA270 PDSX270 271-A120 271AA120 4010271 B41A271 PDSA271 PDSX271 276-A120 276AA120 4010276 B41A276 PDSA276 PDSX276 277-A120 277AA120 4010277 B41A277 PDSA277 PDSX277 277U-AA120 n/a PDSX277U 278-A120 278AREQ 41-278RQ 41A278RQ PDA278RQ PDX278RQ 278-A320 278ARES 41-278RP 41A278RP PDA278RP PDX278RP 820-A120 820AA120 4010-820 B41A820 PDSA820 PDSX820 834-A120 834AA120 4010834 B41A834 PDSA834 PDSX834 835-W120 835AW120 4010-835 B41A835 PDSA835 PDSX835 837-Q120 837AQ120 4010837P B41A837P (*CCI) PDSA837P (*CCI) PDSX837P 837 Health Care Claim: Dental 837-Q220 837AQ220 4010837D B41A837D PDSA837D PDSX837D 837 Health Care Claim: Institutional 997 Functional Acknowledgement 837-Q320 837AQ320 4010837I B41A837I PDSA837I PDSX837I n/a n/a n/a n/a PDSA997 4010-997 PDF (www.wpcedi.com) 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) 004010X092 004010X092A1 004010X092 004010X092A1 004010X093 004010X093A1 004010X093 004010X093A1 004010 004010X093 004010X093A1 004010X094 004010X094A1 004010X094 004010X094A1 004010X061 004010X061A1 004010X095 004010X095A1 004010X091 004010X091A1 004010X098 004010X098A1 004010X097 004010X097A1 004010X096 004010X096A1 Notes BHT02=13 BHT02=11 Uses SV1 segment Uses SV3 segment Uses SV2 segment Generic X12-4010 997 (no HIPAA rules), although PDSA997 does generate structure records in InStream DTL file. HIPAA and Other Healthcare Related Guidelines Page 4

Table 2 - X12-4050 Version X12-4050 Document Name EDISIM Non-Addenda HIPAA Validator Addenda No SVALU Records GuidelinePlus only Addenda SVALU Records PDF (www.wpcedi.com) Value in GS08 Notes 275 Additional Information to Support a Health Care Claim or Encounter 277 Health Care Claim Request for Additional Information / 275-X151 4050-275 n/a 275-X151.pdf 004050X151 277-X150 4050-277 n/a 277-X150.pdf 004050X151 HIPAA and Other Healthcare Related Guidelines Page 5

Document Name EDISIM ** Table 4 - X12-5010 June 2010 Errata HIPAA Validator * X12-5010 June 2010 Errata HIPAA Validator No SVALU Records GuidelinePlus only DS, RG, TI 270 Eligibility, Coverage or Benefit Inquiry 270-X279 270-X279 5010-270X279 PDSA5010270X279 PDSX5010270X279 271 Eligibility, Coverage or Benefit Information 271-X279 271-X279 5010-271X279 PDSA5010271X279 PDSX5010271X279 276 Health Care Claim Status Request 276-X212 276-X212 5010-276X212 PDSA5010276X212 PDSX5010276X212 276 Health Care Claim Status Request Medicare n/a 5010-MEDICARE- 276X212 PDSA5010MEDICARE- 276X212 277 Health Care Claim Status Response 277-X212 277-X212 5010-277X212 PDSA5010277X212 PDSX5010277X212 277 Health Care Claim Status Response Unsolicited 277U-X212 277U-X212 n/a n/a PDSX5010-277UX212 277 Health Care Claim Acknowledgement 277CA-X214 277CA-X214 5010-277CAX214 PDSA5010277CAX214 PDSX5010277CAX214 277 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-X166 824-X186A1 5010-MEDICARE- 277X212 PDSA5010MEDICARE- 277X212.std 278X217Q 278X217Q 5010-278X217Q PDSA5010278X217Q PDSX5010278X217Q 278X217R 278X217R 5010-278X217R PDSA5010278X217R PDSX5010278X217R 820-X218 820-X218 5010-820 PDSA5010820 PDSX5010820 824-X166 824-X186A1 PDF (www.wpc-edi.com) x203_270_271.pdf x203_270_271.pdf 276-X212-5010.pdf Value in GS08 005010X279A1 005010X279A1 005010X212 HIPAA and Other Healthcare Related Guidelines Page 6 none 277-X212-5010.pdf X214_277CA.pdf none 278X217Q- 5010.pdf 005010X212 005010X212 005010 005010X212 005010X214 005010X212 005010X217 278X217R-5010.pdf 005010X217 820-x218-5010.pdf n/a n/a 824-x166-5010.pdf 824-x186A1-5010.pdf 834 Benefit Enrollment and Maintenance 834-X220 834-X220 5010-834 PDSA5010834 PDSX5010834 835 Health Care Claim Payment/Advice 835-X221 835-X221 5010-835 PDSA5010835 PDSX5010835 837D Health Care Claims Dental 837-X224 837-X224 5010837D PDSA5010837D PDSX5010837D 837I Health Care Claim Institutional 837-X223 837-X223 5010837I PDSA5010837I PDSX5010837I 834-x220-5010.pdf 835-X221-5010.pdf 837-x224-5010.pdf 837-x223-5010.pdf 005010X218 005010X166 005010X186A1 005010X220A1 005010X221A1 Notes BHT02=01, 13, or 36 BHT02=11 005010X224A2 Uses SV1 segment 005010X223A2 Uses SV3 segment

Document Name 837I Health Care Claim Institutional Medicare A EDISIM ** HIPAA Validator * X12-5010 June 2010 Errata HIPAA Validator No SVALU Records n/a n/a 5010- MEDICAREA GuidelinePlus only DS, RG, TI 837P Health Care Claim Professional 837-X222 837-X222 5010837P (*CCI) PDSA5010837P (*CCI) PDSX5010837P PDF (www.wpc-edi.com) Value in GS08 Notes PDSA5010MEDICAREA none 005010X223A2 Uses SV2 segment 837-x222-5010.pdf 005010X222A1 837P Health Care Claim Professional Medicare B n/a n/a 5010- MEDICAREB (*CCI) PDSA5010MEDICAREB (*CCI) none 005010X222A1 HIPAA and Other Healthcare Related Guidelines Page 7

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-X314 275-X314 6020-275X314 PDSA6020-275X314 PDSX6020-275X314 275-X316 275-X316 6020-275X316 PDSA6020-275X316 PDSX6020-275X316 PDF (www.wpc-edi.com) 275-X314-6020.pdf 275-X316-6020.pdf Value in GS08 006020X314 006020X316 277-X228 277-X228 n/a PDSX5010-277X228 277-X228-5010.pdf 005010X228 277-X213 277-X213 n/a PDSX5010-277X213 277-X213-5010.pdf 005010X213 277-X313 277-X313 6020-277X313 PDSA6020-277X313 PDSX6020-277X313 278X215I 278X215I 5010-278X215I PDSA5010-278X215I PDSX5010-278X215I 278X215R 278X215R 5010-278X215R PDSA5010-278X215R PDSX5010-278X215R 278X216A 278X216A 5010-278X216A PDSA5010-278X216A PDSX5010-278X216A 278X216N 278X216N 5010-278X216N PDSA5010-278X216N PDSX5010-278X216N 820-X306 820-X306 5010-820X306 PDSA5010-820X306 PDSX5010-820X306 277-X313-6020.pdf 278-X215I-5010.pdf 278-X215R-5010.pdf 278-X216A-5010.pdf 278-X216N-5010.pdf 820-x306-5010.pdf 006020X313 005010X215 005010X215 005010X216 005010X216 005010X306 n/a 820-X306 5010-HIX-820X306 PDSA5010HIX-820X306 No PDF 005010X306 HIPAA and Other Healthcare Related Guidelines Page 8

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-X220 5010-HIX- 834X220 HIPAA Validator No SVALU Records GuidelinePlus only DS, RG, TI PDSA5010HIX- 834X220 834-X307 834-X307 5010-834X307 PDSA5010-834X307 PDSX5010-834X307 837-X300 837-X300 5010-837X300 PDSA5010-837X300 PDSX5010-837X300 837-X299 837-X299 5010-837X299 PDSA5010-837X299 PDSX5010-837X299 837-X298 837-X298 5010-837X298 PDSA5010-837X298 PDSX5010-837X298 5010-997 5010-997 n/a n/a PDSX5010997 999-X231 999-X231 5010-999X231 PDSA5010-999X231 PDSX5010-999X231 PDF (www.wpc-edi.com) No PDF 834-x307-5010.pdf 837-x300-5010.pdf 837-x299-5010.pdf 837-x298-5010.pdf Value in GS08 005010X220A1 005010X307 005010X300 005010X299 005010X298 No PDF 005010 999_X231.pdf 005010 005010X231 HIPAA and Other Healthcare Related Guidelines Page 9

Table 6 Healthcare Guidelines for TIBCO Foresight Community Manager Guideline Name Purpose Notes FSSD5010-270X279 FSSD5010-271X279 FSSD5010-276X212 FSSD5010-277X212 FSSD5010-278X217REQ FSSD5010-278X217RES FSSD5010-820X218 FSSD5010-834X220 FSSD5010-835X221 FSSD5010-837DX224 FSSD5010-837IX223 FSSD5010-837PX222 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