HIPAA Guidelines
This document lists guidelines provided with the following TIBCO Foresight products: EDISIM, HIPAA Validator Desktop, and TIBCO Foresight Instream. They include X12-4010, X12-4050, X12-5010 Errata, Public Companion Guides, and other Healthcare related guidelines.
Notes
-
X12-4010 —supported, however changes are no longer being incorporated into these guidelines.
-
X12-5010 before June 2010 Errata —supported, however these guidelines are no longer shipped with TIBCO Foresight products.
Table 1 - X12-4010
|
|
Document Name |
EDISIM |
EDISIM |
HIPAA Validator Desktop or Instream |
HIPAA Validator Desktop or Instream |
GuidelinePlus |
(www.wpc-edi.com)
|
Value in GS08 |
Notes |
|---|---|---|---|---|---|---|---|---|---|
|
270 |
Eligibility, Coverage or Benefit Inquiry |
270-A120 |
270AA120 |
4010270 |
B41A270
|
PDSA270 PDSX270 |
X092.pdf |
004010X092 004010X092A1 |
|
|
271 |
Eligibility, Coverage or Benefit Information |
271-A120 |
271AA120 |
4010271 |
B41A271
|
PDSA271 PDSX271 |
X092.pdf |
004010X092 004010X092A1 |
|
|
276 |
Health Care Claim Status Request |
276-A120 |
276AA120 |
4010276
|
B41A276 |
PDSA276 PDSX276 |
X093.pdf |
004010X093 004010X093A1 |
|
|
277 |
Health Care Claim Status Notification |
277-A120 |
277AA120 |
4010277 |
B41A277
|
PDSA277 PDSX277 |
X093.pdf |
004010X093 004010X093A1 |
|
|
277 |
Health Care Claim Status Notification - unsolicited |
|
277U-AA120 |
|
|
n/a
|
|
004010 004010X093 004010X093A1 |
|
|
278 |
Health Care Services Review Information – Request for Review |
278-A120 |
278AREQ |
41-278RQ |
41A278RQ
|
PDA278RQ PDX278RQ |
X094.pdf |
004010X094 004010X094A1 |
BHT02=13 |
|
278 |
Health Care Services Review Information – Response to Request for Review |
278-A320 |
278ARES |
41-278RP |
41A278RP
|
PDA278RP PDX278RP |
X094.pdf |
004010X094 004010X094A1 |
BHT02=11 |
|
820 |
Payment Order / Remittance Advice |
820-A120 |
820AA120 |
4010-820 |
B41A820
|
PDSA820 PDSX820 |
X061.pdf |
004010X061 004010X061A1 |
|
|
834 |
Benefit Enrollment and Maintenance |
834-A120 |
834AA120 |
4010834 |
B41A834
|
PDSA834 PDSX834 |
X095.pdf |
004010X095 004010X095A1 |
|
|
835 |
Health Care Claim Payment/Advice |
835-W120 |
835AW120 |
4010-835 |
B41A835
|
PDSA835 PDSX835 |
X091.pdf |
004010X091 004010X091A1 |
|
|
837 |
Health Care Claim: Professional |
837-Q120 |
837AQ120 |
4010837P |
B41A837P (*CCI) |
PDSA837P (*CCI) PDSX837P |
X098.pdf |
004010X098 004010X098A1 |
Uses SV1 segment |
|
837 |
Health Care Claim: Dental |
837-Q220 |
837AQ220 |
4010837D |
B41A837D
|
PDSA837D PDSX837D |
X097.pdf |
004010X097 004010X097A1 |
Uses SV3 segment |
|
837 |
Health Care Claim: Institutional |
837-Q320 |
837AQ320 |
4010837I |
B41A837I
|
PDSA837I PDSX837I |
X096.pdf |
004010X096 004010X096A1 |
Uses SV2 segment |
|
997 |
Functional Acknowledgement |
n/a |
n/a |
n/a |
n/a |
PDSA997 4010-997 |
Generic X12-4010 997 (no HIPAA rules), although PDSA997 does generate structure records in Instream DTL file. |
||
Table 2 - X12-4050
|
|
Document Name |
EDISIM
|
HIPAA Validator Desktop or Instream
|
GuidelinePlus
Types 1-2 |
(www.wpc-edi.com)
|
Value in GS08 |
Notes |
|---|---|---|---|---|---|---|---|
|
275 |
Additional Information to Support a Health Care Claim or Encounter |
275-X151 |
4050-275 |
n/a |
275-X151.pdf |
004050X151 |
|
|
277 |
Health Care Claim Request for Additional Information |
277-X150 |
4050-277 |
n/a |
277-X150.pdf |
004050X151 |
|
Table 3 - X12-5010 June 2010 Errata
|
|
Document Name |
EDISIM |
HIPAA Validator Desktop or Instream |
HIPAA Validator Desktop or Instream
|
GuidelinePlus Instream only DS, RG, TI |
(www.wpc-edi.com)
|
Value in GS08 |
Notes |
|---|---|---|---|---|---|---|---|---|
|
270 |
Eligibility, Coverage or Benefit Inquiry |
270-X279 |
270-X279 |
5010-270X279 |
PDSA5010270X279 |
x203_270_271.pdf |
005010X279A1 |
|
|
271 |
Eligibility, Coverage or Benefit Information |
271-X279 |
271-X279 |
5010-271X279 |
PDSA5010271X279 PDSX5010271X279 |
x203_270_271.pdf |
005010X279A1 |
|
|
276 |
Health Care Claim Status Request |
276-X212 |
276-X212 |
5010-276X212 |
PDSA5010276X212 PDSX5010276X212 |
276-X212-5010.pdf |
005010X212
|
|
|
276 |
Health Care Claim Status Request – Medicare |
n/a |
|
5010-MEDICARE-276X212 |
PDSA5010MEDICARE- 276X212 |
none |
005010X212 |
|
|
277 |
Health Care Claim Status Response |
277-X212 |
277-X212 |
5010-277X212 |
PDSA5010277X212 PDSX5010277X212 |
277-X212-5010.pdf |
005010X212
|
|
|
277 |
Health Care Claim Status Response – Unsolicited |
277U-X212 |
277U-X212 |
n/a |
n/a
|
|
005010 |
|
|
277 |
Health Care Claim Acknowledgement |
277CA-X214 |
277CA-X214 |
5010-277CAX214 |
PDSA5010277CAX214 |
X214_277CA.pdf |
005010X214 |
|
|
277 |
Health Care Claim Status Response- Medicare |
n/a |
|
5010-MEDICARE-277X212 |
PDSA5010MEDICARE- 277X212.std |
none |
005010X212 |
|
|
278 |
Health Care Services Request for Review |
278X217Q |
278X217Q |
5010-278X217Q |
PDSA5010278X217Q PDSX5010278X217Q |
278X217Q-5010.pdf |
005010X217 |
BHT02=01, 13, or 36 |
|
278 |
Health Care Services Response to Review |
278X217R |
278X217R |
5010-278X217R |
PDSA5010278X217R PDSX5010278X217R |
278X217R-5010.pdf |
005010X217 |
BHT02=11 |
|
820 |
Payroll Deducted and Other Group Premium Payment for Insurance Products |
820-X218 |
820-X218 |
5010-820 |
PDSA5010820 PDSX5010820 |
820-x218-5010.pdf |
005010X218 |
|
|
824 |
Application Advice |
824-X166 824-X186A1 |
824-X166 824-X186A1 |
n/a |
n/a |
824-x166-5010.pdf 824-x186A1-5010.pdf |
005010X166 005010X186A1 |
|
|
834 |
Benefit Enrollment and Maintenance |
834-X220 |
834-X220 |
5010-834 |
PDSA5010834 PDSX5010834 |
834-x220-5010.pdf
|
005010X220A1 |
|
|
835 |
Health Care Claim Payment/Advice |
835-X221 |
835-X221 |
5010-835 |
PDSA5010835 |
835-X221-5010.pdf |
005010X221A1
|
|
|
837D |
Health Care Claims Dental |
837-X224 |
837-X224 |
5010837D |
PDSA5010837D |
837-x224-5010.pdf |
005010X224A2
|
Uses SV1 segment |
|
837I |
Health Care Claim Institutional |
837-X223 |
837-X223 |
5010837I |
PDSA5010837I |
837-x223-5010.pdf |
005010X223A2
|
Uses SV3 segment |
|
837I |
Health Care Claim Institutional – Medicare A |
n/a |
n/a |
5010-MEDICAREA |
PDSA5010MEDICAREA |
none |
005010X223A2 |
Uses SV2 segment |
|
837P |
Health Care Claim Professional |
837-X222 |
837-X222 |
5010837P (*CCI) |
PDSA5010837P (*CCI) |
837-x222-5010.pdf |
005010X222A1 |
|
|
837P |
Health Care Claim Professional – Medicare B |
n/a |
n/a |
5010-MEDICAREB (*CCI) |
PDSA5010MEDICAREB (*CCI) |
none |
005010X222A1 |
|