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TIBCO Foresight HIPAA Validator Manual

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TIBCO Foresight® HIPAA Validator®
Desktop
Standards and Guidelines Reference
Manual
Version 9.2.0
February 2022
Copyright © 2001-2022. TIBCO Software Inc. All Rights Reserved.

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  • Page 1 TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual Version 9.2.0 February 2022 Copyright © 2001-2022. TIBCO Software Inc. All Rights Reserved.

  • Page 2: Table Of Contents

    Flat-File Standards Guideline Overview Life Cycle of a Guideline Using a Merged Guideline Anatomy of a Guideline Explanation for Segment Table Example Explanation for Segment Detail Page Example Supported Guidelines TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 3 NCPDP in TIBCO Foresight Products Sample Data and Instream Scripts Terminology Big Picture Codes Elements Segments Example Batch Data with no 1.1 “Enveloping” TIBCO Documentation and Support Services Legal and Third-Party Notices TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 4: Introduction

    Production Guidelines Production guidelines are guidelines for TIBCO Foresight® Instream® and TIBCO Foresight® HIPAA Validator Desktop® that you create by merging a user guideline with a TIBCO Foresight guideline. XML and Flat-File Guidelines Unlike EDI, XML and flat-file guidelines are not firmly based on standards. Therefore, you will notice differences in how they are implemented in TIBCO Foresight products.

  • Page 5: Guideline Management With Tibco Foresight Products

    (production) guidelines, and specific business rules.   TIBCO Enterprise-wide, partner- Uses guidelines to collect statistics, Foresight® specific, and detailed view, and correct EDI errors. Transaction transaction reporting and TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 6: Guideline Merging With Guidemerge

      Production guidelines are guidelines for Instream and HIPAA Validator Desktop that you create by merging a user guideline with a TIBCO Foresight guideline. HIPAA-based Production guidelines contain type 1-7 edits. GuideMerge installs with HIPAA Validator® Desktop, EDISIM®, and Windows versions of Instream.
  • Page 7 7 | Introduction                 TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 8: Standards Overview

    Purchase Order Shipping Notice Functional Acknowledgment Acceptance/ Rejection Advice Supported Standards provides a detailed list of the standards and guidelines that TIBCO Foresight products support at some level.     TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 9: Supported Standards

    Supported by EDISIM, Instream, and HIPAA Validator Desktop. (A note may indicate partial support.)   Shipped with EDISIM, Instream, and HIPAA Validator Desktop. Additionally, these TIBCO Foresight products support general XML schema and flat-file definitions, although they do not currently ship with organization schemas (e.g., MISMO). Please see XML Standards Flat-File Standards for more information.

  • Page 10: X12 Standards

    3040, 3041, 3042 3050, 3051, 3052 3060, 3061, 3062 3070, 3071, 3072 4010, 4011, 4012 4010 only 4020, 4021, 4022 4030, 4031, 4032 4040, 4041, 4042 4050, 4051, 4052 4050 only TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 11 6010, 6011, 6012 6020, 6021, 6022 6030, 6031, 6032 6040, 6041, 6042 6050, 6051, 6052 7010, 7011, 7012 7020, 7021, 7022 7030, 7031, 7032,  7040, 7041, 7042 7050, 7051, 7052 7060 8010 TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 12: X12 Derivatives

    HIPAA Validator Desktop. EDISIM will allow the creation of guidelines with additional rules that can be merged with these encrypted guidelines, but EDISIM does not allow the encrypted HIPAA guidelines to be viewed, printed, or edited. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 13: Medical Standards

    UB-92 6.0 * Editor, Validator only * does not ship with EDISIM. Contact TIBCO Foresight support. ** To use this guideline a minimum of Instream 8.4.0 Hotfix 4 and EDISIM 6.14.0 Hotfix 3 are required. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference...

  • Page 14: Edifact Standards

    D94A, D94Av4, D94B, D94Bv4 D95A, D95Av4, D95B, D95Bv4 D96A, D96Av4, D96B, D96Bv4 D96A only (Instream only) D97A, D97Av4, D97B, D97Bv4 D98A, D98Av4, D98B, D98Bv4 D99A, D99Av4, D99B, D99Bv4 D00A, D00Av4, D00B, D00Bv4 TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 15 D10A, D10Av4, D10B, D10Bv4 D11A, D11AV4 D11B*, D11BV4* D12A*, D12AV4*, D12B*, D12BV4* D13A*, D13AV4, D13B*, D13BV4* D14A, D14AV4*, D14B*, D14BV4* D15AC, D15AV4*, D15B*, D15BV4* D16A*, D16AV4*, D16B*, D16BV4* D17A*, D17AV4*, D17B*, D17BV4* TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 16: Edifact Derivatives

    EANCOM93 EAN97 (Version 3 and EAN02 (Syntax 3 and Other Standards Version Shipped with EDISIM? Shipped with Instream/HIPAA Validator Desktop? ACH (ACH_CCDp and All except TDG, Comparator, ACD_CTX) and Analyzer TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 17: Xml Standards

    ‘guidelines’, along with custom enveloping. You can use these flat-file guidelines in EDISIM Validator and Instream/HIPAA Validator Desktop to validate flat-file data, and to create HTML reports of validation results. EDISIM TDG and Comparator do not support flat-file guidelines. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 18: Guideline Overview

    Customized guidelines start life in EDISIM Standards Editor. Taking a published guideline, you can modify the usage, codes, values, and other characteristics to define exactly how the data should be. TIB_fsp_edisim_<n.n>_fseditor.pdf BusinessRules.pdf explain how to do this. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 19: Using A Merged Guideline

    Since EDISIM can only handle HIPAA types 1, 2, and 8, we have to merge in types 3-7. These are in special HIPAA guidelines that ship with HIPAA Validator Desktop, Instream, Transaction Insight, Community Manager®, and other HIPAA-specific products. We use GuideMerge for this. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 20 (APF), the customer error message file, external tables or databases, the $dir.ini, etc., include these in Instream too. We now have guidelines and associated files in these places: TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 21 After initial validation, the detail results file is imported into Transaction Insight. A Transaction Insight user corrects the data and it is sent to Instream to revalidate. Typically, the two instances of Instream are not on the same server. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 22 22 | Guideline Overview A more complete overview of a typical process like this might be: TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 23: Anatomy Of A Guideline

    23 | Anatomy of a Guideline Anatomy of a Guideline The following pages show an annotated example guideline document. Unused segments were not printed in this example. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 24: Explanation For Segment Table Example

    Segment name or description. You can change this in EDISIM Standards Editor. To change it in a particular location, click on the segment in the TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 25 EDISIM Doc Builder. You can change these in Document Builder. Open the guideline and choose Profile | Options | Formatting tab. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 26: Explanation For Segment Detail Page Example

    Purpose field in the bottom pane’s Detail tab. To change it throughout the transaction, make the change in the Segments dictionary. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 27 Element dictionary and use the Type field in the bottom pane’s Detail tab. See also DataTypes.pdf in EDISIM’s Documentation directory. This is a global change.   Minimum length and maximum length. Change in EDISIM Standards TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 28 EDISIM Standards Editor. Click on the element in the top pane and use the Code Values tab at the bottom. You can also work with codes in the element, composite, or segment dictionary TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 29: Supported Guidelines

    Foresight HIPAA guidelines For those using TIBCO Foresight HIPAA validation products, these guidelines in EDISIM contain types 1 and 2 edits. HIPAA-based TIBCO Foresight guidelines in Validator include these same EDISIM guidelines plus additional guidelines with types 1-6 edits. User Guidelines that you create in EDISIM Standards Editor.

  • Page 30: Hipaa Guidelines

    30 | Supported Guidelines 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  1.
  • Page 31 837-Q220 837AQ220 4010837D B41A837D PDSA837D X097.pdf 004010X097 Uses SV3 segment   PDSX837D 004010X097A1 Health Care Claim: Institutional 837-Q320 837AQ320 4010837I B41A837I PDSA837I X096.pdf 004010X096 Uses SV2 segment   PDSX837I 004010X096A1 TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 32 DS, RG, TI edi.com)   Types 1-2 No SVALU Records Types 1-7 Types 1-7 Types 1-2 Types 1-2 Eligibility, Coverage or Benefit Inquiry 270-X279 270-X279 5010-270X279 PDSA5010270X279 x203_270_ 005010X279A1   PDSX5010270X279 271.pdf TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 33 Payroll Deducted and Other Group Premium 820-X218 820-X218 5010-820 PDSA5010820 820-x218- 005010X218   Payment for Insurance Products PDSX5010820 5010.pdf Application Advice 824-X166 824-X166 824-x166- 005010X166   5010.pdf 824-X186A1 824-X186A1     005010X186A1     824-x186A1- 5010.pdf TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 34 Health Care Claim Professional 837-X222 837-X222 5010837P (*CCI) PDSA5010837P (*CCI) 837-x222- 005010X222A1   PDSX5010837P 5010.pdf 837P Health Care Claim Professional – Medicare B 5010-MEDICAREB (*CCI) PDSA5010MEDICAREB none 005010X222A1   (*CCI) TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 35: Healthcare Guidelines Non-Hipaa Mandated

    278-X216A- 005010X216 PDSX5010-278X216A 5010.pdf Health Care Services Review Information - Notification 278X216N 278X216N 5010-278X216N PDSA5010-278X216N 278-X216N- 005010X216 PDSX5010-278X216N 5010.pdf Health Insurance Exchange: Related Payment  820-X306 820-X306 5010-820X306 PDSA5010-820X306 820-x306- 005010X306 TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 36 Professional, Post-Adjudication Claims Data Reporting 837-X298 837-X298 5010-837X298 PDSA5010-837X298 837-x298- 005010X298 PDSX5010-837X298 5010.pdf Functional Acknowledgment 5010-997 5010-997 No PDF 005010 PDSX5010997   Implementation Acknowledgment 999-X231 999-X231 5010-999X231 PDSA5010-999X231 999_X231.pdf 005010 PDSX5010-999X231 005010X231 TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 37: Healthcare Guidelines For Tibco Foresight® Community Manager

      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 TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 38: General Guidelines

    Invoice PDSAGM5010-810 TIBCO Foresight Transaction Insight Standard Edition Payment Order/Remittance Advice PDSAGM5010-820 Purchase Order PDSAGM5010-850 Purchase Order Acknowledgment PDSAGM5010-855 Ship Notice/Manifest PDSAGM5010-856 Purchase Order Change Request – Buyer Initiated PDSAGM5010-860 TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 39: Appendix A: Hl7 Standards

    39 | Appendix A: HL7 Standards Appendix A: HL7 Standards This section describes how to use HL7 transactions, also known as “messages”, in TIBCO Foresight products. Health Level Seven International (HL7) has data interchange standards for health information transactions. HL7 Version 2 Messaging Standards versions as listed below are supported by TIBCO Foresight validation products.

  • Page 40: Sample Data And Instream Scripts

      Financial Management   Observation Reporting   Master Files   Medical Records/Information Management   Scheduling (View Brief)   Patient Referral   Patient Care   Clinical Laboratory Automation   Application Management TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 41: Hl7 Specific Information

    End File Segment (FTS). HL7 Specific Information Users who are familiar with EDISIM, Instream, HIPAA Validator Desktop, and Foresight Translator from working with X12 EDI will find the following differences when working with TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 42 Message Loop Segment Group Segment Segment Sub-Composite Members Field Sub-Components Element Fields Code Set Table Requirements Coding The following Requirements characters are used in the Requirements field in HL7 messages: TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 43 43 | Appendix A: HL7 Standards Character X12 Meaning HL7 Meaning Mandatory Required Optional Optional Conditional Conditional (none) Not Used (none) Backward Compatibility (none) Withdrawn Sub-Composites Composites in HL7 transactions may contain sub-composites. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 44 Batch Header Segment GS (optional) (includes delimiter overrides) Message Header Segment (includes delimiter overrides) (none) Message Trailer Segment Batch Trailer Segment GE (optional, but required if BSH is used) TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 45: Hl7 Data Types

    Charge code and date Channel calibration parameters Channel definiion Coded ENTRY Coded element with formatted values Composite ID with check digit Composite Composite ID number and name Coded with no exceptions TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 46 Encapsulated data Entity identifier Financial class Family name Formatted text data Hierarchic designator ID  Coded value for HL7-defined tables Coded value for user-defined tables Job code/class Multiplexed array Money Numeric array TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 47 Query input parameter list Query selection criteria Row column definition Repeat interval Reference pointer Street address Scheduling class value pair Structured numeric Sort order String data Time Timing quantity Timestamp TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 48 Text data Visiting hours Version identifier Extended address Extended composite ID number and name for persons Extended composite name and identification number for organizations Extended person name Extended telecommunications number TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 49: Appendix B: Ncpdp Standards

    49 | Appendix B: NCPDP Standards Appendix B: NCPDP Standards This section describes how to use NCPDP transactions in TIBCO Foresight products. The National Council for Prescription Drug Programs (NCPDP) has data interchange standards for pharmacy services. NCPDP's Telecommunication Standard Version 5.1 and D.0 are supported by TIBCO Foresight validation products (EDISIM, HIPAA Validator...

  • Page 50: Sample Data And Instream Scripts

    ✓   V_NCPDP_51_ Scripts Validates NCPDP_BillRequest_ BillRequest 51.txt. Terminology NCPDP Interchange Batch Functional Group none Transaction Set Transmission Loop none Claim or other application document Transaction Segment Segment Composite none TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 51: Big Picture

    N1 – Information Reporting   N2 – Information Reversal   N3 – Information Rebill Prior Authorization   P1 – Prior Authorization Request and Billing   P2 – Prior Authorization Reversal TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 52: Codes

      Each element in the transaction sections of the batch (in the claim itself, for example) starts with the Field Separator character (x1C). Elements in header segments have no TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 53 These re values specified in the sta, not code lists managed by outside organizations, as in X12. Alphanumeric Data is left justified with spaces padded on the right. All letters are uppercase. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 54 Now move to the right until you find the column for signed negative graphic. The value that represents 5 and signed negative is N. Negative $19.95 appears as 199N in the data. Value Signed Positive Graphic Signed Negative Graphic TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 55: Segments

    The first segment in a batch is always the 00 Header segment, which is fixed length without delimiters. It serves the same function as X12’s ISA.   The GIT segment that you see in TIBCO Foresight products is for requests. It contains TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...
  • Page 56 56 | Appendix B: NCPDP Standards the reference number from the G1 segment, plus the elements from the Request Header Segment QT. GIT is a TIBCO Foresight structure and is not part of the standard.   The GIR segment that you see in TIBCO Foresight products is for responses. It contains the reference number from the G1 segment, plus the elements from the Response Header Segment RT.

  • Page 57: Example Batch

    (requests) rather than responses. Start of the first G1 record. Notice the B1, indicating that these will be Billing TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 58: Data With No 1.1 "Enveloping

    The GI tag is immediately followed by the fixed-length elements in the Request Header Segment (QH in TIBCO Foresight products) or the Response Header Segment (RH in TIBCO Foresight products). This is underlined in the example. Each segment ends with a segment terminator hex 1E, which displays as a hyphen in this example.
  • Page 59 If the data starts with (as in 51B1OKA01 …), then it is a response and you can put the contents of HeaderResponse.NCPDP in front of it and Trailer.NCPDP after it. TIBCO Foresight® HIPAA Validator® Desktop Standards and Guidelines Reference Manual...

  • Page 60: Tibco Documentation And Support Services

    Q&A forums, product wikis, and best practices. It also offers access to extensions, adapters, solution accelerators, and tools that extend and enable customers to gain full value from TIBCO products. In addition, users can submit and vote on feature requests from within the TIBCO Ideas Portal.

  • Page 61: Legal And Third-Party Notices

    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.
  • Page 62 INDIRECTLY, BY OTHER DOCUMENTATION WHICH ACCOMPANIES THIS SOFTWARE, INCLUDING BUT NOT LIMITED TO ANY RELEASE NOTES AND "READ ME" FILES. This and other products of TIBCO Software Inc. may be covered by registered patents. Please refer to TIBCO's Virtual Patent Marking document (https://www.tibco.com/patents) for details.

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