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Copyright © TIBCO Software Inc. All Rights Reserved


Chapter 1 Introduction to HIPAA Protocol : Overview

Overview
The Health Insurance Portability and Accountability Act of 1996, known as “HIPAA,” is a federal law that covers a number of important health care issues, such as providing consumers with greater access to health care insurance, and insuring the privacy of health care data. The law also includes measures designed to reduce administrative costs in the health care industry by providing standards for electronic transactions between the various entities within the industry, such as health care providers and insurers.
The Administrative Simplification portion of the law deals with electronic transactions and code sets requirements. TIBCO BusinessConnect EDI Protocol HIPAA Edition powered by Instream contains additional functionality for TIBCO BusinessConnect EDI Protocol powered by Instream, which allows customers to be compliant with the electronic transactions and code sets requirements of the Administrative Simplification portion of HIPAA.
TIBCO BusinessConnect EDI Protocol HIPAA Edition powered by Instream also provides for validation of National Provider Identifiers (NPI), which is another part of HIPAA’s Administrative Simplification.
Electronic Transactions
HIPAA transactions are activities involving the electronic transfer of health care information for specific purposes. Under HIPAA, if a health care provider engages in one of the identified transactions, they must comply with the standard for that transaction. HIPAA requires every provider who does business electronically to use the same health care transactions, code sets, and identifiers.
The electronic transaction standards for the healthcare industry are specified by the ASC X12N Subcommittee of The American National Standards Institute (ANSI) and the National Council for Prescription Drug Programs (NCPDP). The NCPDP standard formats are used by retail pharmacies for drug claim transactions.
The following is a list of the electronic transaction standards mandated by HIPAA:
Document Structure
HIPAA transactions are specialized versions of X12 transactions. As such, a HIPAA document has the same structure and uses the same delimiters as an X12 document. To understand the structure of an X12 document and the use of delimiters in an X12 document, see TIBCO BusinessConnect EDI Protocol powered by Instream, X12 Configuration, Chapter 1, "Document Structure and Delimiters."
Acknowledgements
The information in the section on Acknowledgements in TIBCO BusinessConnect EDI Protocol powered by Instream, X12 Configuration also applies to HIPAA transactions.
Additionally, TIBCO BusinessConnect EDI Protocol HIPAA Edition powered by Instream supports application level acknowledgements that are used to provide the validation results on the HIPAA specific business rules for a transaction. For information on these application level acknowledgements that are specific to TIBCO BusinessConnect EDI Protocol HIPAA Edition powered by Instream, see HIPAA Acknowledgement Properties.
Design Time Validation of HIPAA Transactions
TIBCO BusinessConnect EDI Protocol HIPAA Edition powered by Instream is used for runtime validation of HIPAA electronic transactions. For design time validation of HIPAA electronic transactions, the product TIBCO Foresight HIPAA Validator Desktop is used.
To use the guidelines shipped with TIBCO BusinessConnect EDI Protocol HIPAA Edition powered by Instream with TIBCO Foresight HIPAA Validator Desktop, you need to copy the HIPAA guidelines from TIBCO BusinessConnect EDI Protocol HIPAA Edition powered by Instream into the appropriate directory for TIBCO Foresight HIPAA Validator Desktop.
For example, to do design time validation of a version 4010 837 Professional transaction do the following:
change directory to BC_HOME/protocols/tibedi/samples/sampleDocs/guidelines/4010_txns
copy PDSA837P.std to FORESIGHT_HOME/Desktop/Database
See the documentation that accompanies TIBCO Foresight HIPAA Validator Desktop for directions on how to use the product to perform validation.
To see a list of the guidelines for each HIPAA transaction, see Chapter 2, HIPAA Transaction Configuration.

Copyright © TIBCO Software Inc. All Rights Reserved
Copyright © TIBCO Software Inc. All Rights Reserved