TIBCO Foresight Products HIPAA and Other Healthcare Related Guidelines List

Transcription

1 TIBCO Foresight Products HIPAA and Other Healthcare Related Guidelines List July 2015 Two-second advantage

2 Important Information SOME TIBCO SOFTWARE EMBEDS OR BUNDLES OTHER TIBCO SOFTWARE. USE OF SUCH EMBEDDED 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. USE OF TIBCO SOFTWARE AND THIS DOCUMENT IS SUBJECT TO THE TERMS AND CONDITIONS OF A LICENSE AGREEMENT FOUND IN EITHER A SEPARATELY EXECUTED SOFTWARE LICENSE AGREEMENT, OR, IF THERE IS NO SUCH SEPARATE AGREEMENT, THE CLICKWRAP END USER LICENSE AGREEMENT WHICH IS DISPLAYED DURING DOWNLOAD OR INSTALLATION OF THE SOFTWARE (AND WHICH IS DUPLICATED IN THE LICENSE FILE) OR IF THERE IS NO SUCH SOFTWARE LICENSE AGREEMENT OR CLICKWRAP END USER LICENSE AGREEMENT, THE LICENSE(S) LOCATED IN THE LICENSE FILE(S) OF THE SOFTWARE. USE OF THIS DOCUMENT IS SUBJECT TO THOSE TERMS AND CONDITIONS, AND YOUR USE HEREOF SHALL CONSTITUTE ACCEPTANCE OF AND AN AGREEMENT TO BE BOUND BY THE SAME. This document contains confidential information that is subject to U.S. and international copyright laws and treaties. No part of this document may be reproduced in any form without the written authorization of TIBCO Software Inc. TIBCO, Two-Second Advantage, TIBCO Foresight Community Manager, TIBCO Foresight, TIBCO Foresight Desktop, TIBCO Foresight, and TIBCO Foresight Translator are either registered trademarks or trademarks of TIBCO Software Inc. in the United States and/or other countries. Enterprise Java Beans (EJB), Java Platform Enterprise Edition (Java EE), Java 2 Platform Enterprise Edition (J2EE), and all Java-based trademarks and logos are trademarks or registered trademarks of Oracle Corporation in the U.S. and other countries. All other product and company names and marks mentioned in this document are the property of their respective owners and are mentioned for identification purposes only. THIS SOFTWARE MAY BE AVAILABLE ON MULTIPLE OPERATING SYSTEMS. HOWEVER, NOT ALL OPERATING SYSTEM PLATFORMS FOR A SPECIFIC SOFTWARE VERSION ARE RELEASED AT THE SAME TIME. SEE THE README FILE FOR THE AVAILABILITY OF THIS SOFTWARE VERSION ON A SPECIFIC OPERATING SYSTEM PLATFORM. THIS DOCUMENT IS PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, OR NON-INFRINGEMENT. THIS DOCUMENT COULD INCLUDE TECHNICAL INACCURACIES OR TYPOGRAPHICAL ERRORS. CHANGES ARE PERIODICALLY ADDED TO THE INFORMATION HEREIN; THESE CHANGES WILL BE INCORPORATED IN NEW EDITIONS OF THIS DOCUMENT. TIBCO SOFTWARE INC. MAY MAKE IMPROVEMENTS AND/OR CHANGES IN THE PRODUCT(S) AND/OR THE PROGRAM(S) DESCRIBED IN THIS DOCUMENT AT ANY TIME. THE CONTENTS OF THIS DOCUMENT MAY BE MODIFIED AND/OR QUALIFIED, DIRECTLY OR INDIRECTLY, BY OTHER DOCUMENTATION WHICH ACCOMPANIES THIS SOFTWARE, INCLUDING BUT NOT LIMITED TO ANY RELEASE NOTES AND "READ ME" FILES. Copyright TIBCO Software Inc. ALL RIGHTS RESERVED. TIBCO Software Inc. Confidential Information General Contact Information TIBCO Software Inc., Foresight Group 655 Metro Place South Suite 900 Dublin OH Phone: (614) Fax: (614) Technical Support support@tibco.com Web: (Note: Entry to this site requires a username and password. If you do not have one, you can request one. You must have a valid maintenance or support contract to use this site.)

3 Contents Table 1 - X Table 2 - X Table 4 - X June 2010 Errata... 5 Table 5 - Healthcare Guidelines Non-HIPAA Mandated... 7 Table 6 Healthcare Guidelines for Community Manager... 8 HIPAA Guideline List Page 1 7/7/2015

4 HIPAA and Other Healthcare Related Guidelines List This document lists guidelines provided with the following TIBCO Foresight products: TIBCO Foresight, TIBCO Foresight HIPAA Validator Desktop, and TIBCO Foresight. They include X , X , X Errata, Public Companion Guides, and other Healthcare related guidelines. Notes 1. X supported, however changes are no longer being incorporated into these guidelines. 2. X before June 2010 Errata supported, however these guidelines are no longer shipped with TIBCO Foresight products. HIPAA Guideline List Page 2 7/7/2015

5 Table 1 - X 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 Review Information Request for Review 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 Non-Addenda Addenda No SVALU Records Version X HIPAA Validator Non-Addenda Addenda No SVALU Recs only Addenda SVALU Recs (PDSA)/ (PDSX) 270-A AA B41A270 PDSA270 PDSX A AA B41A271 PDSA271 PDSX A AA B41A276 PDSA276 PDSX A AA B41A277 PDSA277 PDSX U-AA120 n/a PDSX277U 278-A AREQ RQ 41A278RQ PDA278RQ PDX278RQ 278-A ARES RP 41A278RP PDA278RP PDX278RP 820-A AA B41A820 PDSA820 PDSX A AA B41A834 PDSA834 PDSX W AW B41A835 PDSA835 PDSX Q AQ P B41A837P (*CCI) PDSA837P (*CCI) PDSX837P 837 Health Care Claim: Dental 837-Q AQ D B41A837D PDSA837D PDSX837D 837 Health Care Claim: Institutional 997 Functional Acknowledgement 837-Q AQ I B41A837I PDSA837I PDSX837I n/a n/a n/a n/a PDSA ( X092.pdf X092.pdf X093.pdf X093.pdf X094.pdf X094.pdf X061.pdf X095.pdf X091.pdf X098.pdf X097.pdf X096.pdf (A1 at end = Addenda) X X092A X X092A X X093A X X093A X X093A X X094A X X094A X X061A X X095A X X091A X X098A X X097A X X096A1 Notes BHT02=13 BHT02=11 Uses SV1 Uses SV3 Uses SV2 Generic X (no HIPAA rules), although PDSA997 does generate structure records in InStream DTL file. HIPAA Guideline List Page 3 7/7/2015

6 Table 2 - X Document Name Non-Addenda Version X Addenda No SVALU Records only Addenda SVALU Records ( Notes 275 Additional Information to Support a Health Care Claim or Encounter 277 Health Care Claim Request for Additional Information / 275-X n/a 275-X151.pdf X X n/a 277-X150.pdf X151 HIPAA Guideline List Page 4 7/7/2015

7 Document Name ** Table 4 - X June 2010 Errata HIPAA Validator * X June 2010 Errata No SVALU Records only DS, RG, TI 270 Eligibility, Coverage or Benefit Inquiry 270-X X X279 PDSA X279 PDSX X Eligibility, Coverage or Benefit Information 271-X X X279 PDSA X279 PDSX X Health Care Claim Status Request 276-X X X212 PDSA X212 PDSX X Health Care Claim Status Request Medicare n/a 5010-MEDICARE- 276X212 PDSA5010MEDICARE- 276X Health Care Claim Status Response 277-X X X212 PDSA X212 PDSX X Health Care Claim Status Response Unsolicited 277U-X U-X212 n/a n/a PDSX UX Health Care Claim Acknowledgement 277CA-X CA-X CAX214 PDSX CAX214 PDSA CAX Health Care Claim Status Response- Medicare Request for Review Response to Review 820 Payroll Deducted and Other Group Premium Payment for Insurance Products n/a 824 Application Advice 824-X X186A MEDICARE- 277X212 PDSA5010MEDICARE- 277X212.std 278X217Q 278X217Q X217Q PDSA X217Q PDSX X217Q 278X217R 278X217R X217R PDSA X217R PDSX X217R 820-X X PDSA PDSX X X186A1 ( x203_270_271.pdf x203_270_271.pdf 276-X pdf X279A X279A X212 HIPAA Guideline List Page 5 7/7/2015 none 277-X pdf X214_277CA.pdf none 278X217Q pdf X X X X X X X217R-5010.pdf X x pdf n/a n/a 824-x pdf 824-x186A pdf 834 Benefit Enrollment and Maintenance 834-X X PDSA PDSX Health Care Claim Payment/Advice 835-X X PDSA PDSX D Health Care Claims Dental 837-X X D PDSA D PDSX D 837I Health Care Claims Institutional 837-X X I PDSA I PDSX I 834-x pdf 835-X pdf 837-x pdf 837-x pdf X X X186A X220A X221A1 Notes BHT02=01, 13, or 36 BHT02= X224A2 Uses SV X223A2 Uses SV3

8 Document Name 837I Health Care Claims Institutional Medicare A ** HIPAA Validator * X June 2010 Errata No SVALU Records n/a n/a MEDICAREA only DS, RG, TI 837P Health Care Claims Professional 837-X X P (*CCI) PDSA P (*CCI) PDSX P 837P Health Care Claims Professional Medicare B n/a n/a MEDICAREB (*CCI) ( Notes PDSA5010MEDICAREA none X223A2 Uses SV2 PDSA5010MEDICAREB (*CCI) 997 Functional Acknowledgment n/a n/a PDSX Implementation Acknowledgment 999-X X X231 PDSA X231 PDSX X x pdf none none X222A X222A1 999_X231.pdf X231 HIPAA Guideline List Page 6 7/7/2015

9 Document Name 275 Health Care Claim or Encounter 275 Health Care Services Review 277 Health Care Claim Request for Additional Information Review Information - Inquiry Review Information - Response Review Information - Acknowledgement Review Information - Notification 820 Health Insurance Exchange: Related Payment 820 Health Insurance Exchange: Related Payment (CMS Companion Guideline) 834 Benefit Enrollment And Maintenance: Health Care Exchange (CMS Companion Guideline) 834 Health Insurance Exchange: Enrollment Table 5 - Healthcare Guidelines Non-HIPAA Mandated ** HIPAA Validator * No SVALU Records only DS, RG, TI 275-X X X314 PDSA X314 PDSX X X X X316 PDSA X316 PDSX X X X X313 PDSA X313 PDSX X X215I 278X215I X215I PDSA X215I PDSX X215I 278X215R 278X215R X215R PDSA X215R PDSX X215R 278X216A 278X216A X216A PDSA X216A PDSX X216A 278X216N 278X216N X216N PDSA X216N PDSX X216N 820-X X X306 PDSA X306 PDSX X HIX- 820X HIX- 834X X HIX-820X306 PDSA5010HIX-820X306 PDSX X306 No type HIX- 834X220 PDSA5010HIX- 834X X X X307 PDSA X307 PDSX X307 ( 275-X pdf 275-X pdf 277-X pdf 278-X215I-5010.pdf 278-X215R-5010.pdf 278-X216A-5010.pdf 278-X216N-5010.pdf 820-x pdf No No 834-x pdf X X X X X X X X X X220A X307 HIPAA Guideline List Page 7 7/7/2015

10 Document Name ** HIPAA Validator * No SVALU Records only DS, RG, TI ( 837D Dental, Post-Adjudication Claims Data Reporting 837-X X X300 PDSA X300 PDSX X x pdf X I 837P Institutional, Post- Adjudication Claims Data Reporting Professional, Post- Adjudication Claims Data Reporting 837-X X X299 PDSA X299 PDSX X X X X298 PDSA X298 PDSX X x pdf 837-x pdf X X298 Table 6 Healthcare Guidelines for TIBCO Foresight Community Manager Guideline Name Purpose Notes FSSD X279 FSSD X279 FSSD X212 FSSD X212 FSSD X217REQ FSSD X217RES FSSD X218 FSSD X220 FSSD X221 FSSD DX224 FSSD IX223 FSSD PX222 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 Guideline List Page 8 7/7/2015