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TIBCO BusinessConnect™ Container Edition - EDI Protocol HIPAA Edition powered by Instream® 1.0.0

# HIPAA Types of Testing

There are seven types of testing recommended for HIPAA transactions. The seven types of testing are those defined in the Transaction Compliance and Certification white paper from WEDI-SNIP.

The following information on testing types is from that white paper.

| • | Type 1: EDI Syntax Integrity Testing: To test an EDI file for valid segments, segment order, element attributes, and numeric values in numeric data elements, validation of X12 syntax, and compliance with X12 rules.

| • | Type 2: HIPAA Syntactical Requirement Testing: To test for HIPAA Implementation Guide-specific requirements, such as repeat counts, used and not used codes, elements and segments, required or intra-segment situational data elements. Testing for non-medical code sets as laid out in the implementation guide and values noted in the Implementation Guide through the X12 code list or table.

| • | Type 3: Balancing: To test the transaction for balanced field totals, financial balancing of claims or remittance advice, and balancing of summary fields, if appropriate.

| • | Type 4: Situation Testing: The testing of specific inter-segment situations described in the HIPAA Implementation Guides, such that if A occurs then B must be populated. This is considered to include the validation of situational fields given values or situations present elsewhere in the file.

Example: If the claim is for an accident, the accident date must be present.

| • | Type 5: External Code List Testing: To test for valid Implementation Guide-specific code list values and other code sets adopted as HIPAA standards. This level of testing not only validates the code sets but also makes sure that the usage is appropriate for any particular transaction and appropriate with the coding guidelines that apply to the specific code list. Validates external code sets and tables such as CPT, ICD9, CDT, NDC, status codes, adjustment reason codes, and their appropriate use for the transaction.

| • | Type 6: Product Types or Line of Service Testing: This testing is required to ensure that the segments or records of data that differ based on certain healthcare services are properly created and processed into claims data formats. These specific requirements are described in the Implementation Guide for the different product types or lines of service.

Example: Ambulance, chiropractic, podiatry, home health, parenteral and enteral nutrition, durable medical equipment, psychiatry, and other specialized services have specific requirements in the Implementation Guide that must be tested before putting the transaction in production. This type of testing only applies to a trading partner candidate that conducts transactions for the specific line of business or product type.

| • | Type 7: Implementation Guide-Specific Trading Partners: The Implementation Guides contain some HIPAA requirements that are specific to Medicare, Medicaid, and Indian Health. Compliance or testing with these payer specific requirements is not required from all trading partners. If the trading partner candidate intends to exchange transactions with one of these Implementation Guide special players, this type of testing is required. When a certification service certifies a trading partner for compliance, the certification service must indicate whether these payer specific requirements were met during the certification process. Other payers and trading partners may have their own specific business requirements. But unless they are listed in the HIPAA Implementation Guides, they are not HIPAA requirements. These non-HIPAA trading partner specific requirements must be tested as part of the business-to-business testing.

Type 1 testing is the validation that is normally performed by BusinessConnect™ Container Edition - EDI Protocol powered by Instream.

Types 2 through 7 are extra levels of validation performed by BusinessConnect™ Container Edition - EDI Protocol HIPAA Edition powered by Instream.

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TIBCO BusinessConnect™ Container Edition - EDI Protocol HIPAA Edition powered by Instream®

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