Fairsail Payflow Cookbook for HIPAA 834 Record Downloads

Transcription

1 Fairsail Payflow Cookbook for HIPAA 834 Record Downloads Version 10 FS-PF-834-CB R010.00

2 Fairsail All rights reserved. This document contains information proprietary to Fairsail and may not be reproduced, disclosed, or used in whole or in part without the written permission of Fairsail. Software, including but not limited to the code, user interface, structure, sequence, and organization, and documentation are protected by national copyright laws and international treaty provisions. This document is subject to U.S. and other national export regulations. Fairsail takes care to ensure that the information in this document is accurate, but Fairsail does not guarantee the accuracy of the information or that use of the information will ensure correct and faultless operation of the service to which it relates. Fairsail, its agents and employees, shall not be held liable to or through any user for any loss or damage whatsoever resulting from reliance on the information contained in this document. Nothing in this document alters the legal obligations, responsibilities or relationship between you and Fairsail as set out in the contract existing between us. This document may contain screenshots captured from a standard Fairsail system populated with fictional characters and using licensed personal images. Any resemblance to real people is coincidental and unintended. All trademarks and service marks mentioned in this document belong to their corresponding owners. FS-PF-834-CB R

3 Contents Contents About this Guide 4 Related Guides 4 Fairsail Payflow Implementer's Guide 4 HIPAA 834 Benefits 5 Resources 5 What You Need to Know About the Third Party System 6 Information From the Customer 8 Configuration 9 Download Configure 9 File Configure 9 Field Mapping 10 Translations for Mapped Fields 11 Index 12 3

4 About this Guide This Payflow Cookbook provides implementation guidance for configuring Payflow to manage a HIPAA 834 format record file download from Fairsail for supply to a third party system. Related Guides Fairsail Payflow Implementer's Guide Coverage summary How to set up, manage, and maintain data flows between Fairsail and other systems, typically for data related to compensation and benefits. The guide includes sections on setting up a benefit selection system on Fairsail. Typical target audience You have responsibility for the implementation of an interface between Fairsail and one or more external services. 4

5 HIPAA 834 Benefits Resources HIPAA 834 Benefits The U.S. HIPAA EDI Benefit Enrollment and Maintenance Set (834) is a standard defining the requirements for electronic data transfer between employers, unions, agencies or associations and healthcare organizations that pay claims or administer insurance. The healthcare organizations are known as payers. The Set covers member enrollment information such as benefits, subscription details, and demographics, and is typically used for health plan enrollment, changes, and termination of membership. Fairsail provides a generic HIPAA 834 file configuration for Payflow, enabling you to build a data feed for a healthcare insurance provider that conforms to the 834 standard. The 834 standard comprises a number of mandatory fields but also allows flexibility in implementation, in part to enable conformity with the requirements of individual States. The generic configuration is intended to ease and accelerate building 834 compliant feeds, but it is not usable without further configuration - there is no single definition of the complete 834 standard that can be implemented without some modification. For each feed you need to: Read the payer's (carrier's) implementation notes for their variant of the 834 standard. Build the data mapping to conform to the details of the implementation. Amend the Header and Footer content to match the requirements of the payer Build and test the link to the payer. Resources Payflow 9.08 or later. Includes the necessary support for 834 Benefits. Earlier versions of Payflow do not support the standard. ASCX12 Benefit Enrollment and Maintenance (834) Consolidated Guide The implementation guide with a full definition of the standard, published by the Accredited Standards Committee X12 of the American National Standards Institute. The definitive reference guide to the 834 standard. Available to buy from: Generic 834 Format File.fs The Payflow configuration file containing the 834 format. Import this file into Payflow to create the Generic 834 Format Payflow Service. The default Service includes: o A Generic834 text Download File. You must edit the Header and Footer content to match the requirements of the carrier. o Outline mapping for 834 Format Segment IDs to HCM Fields. You must edit the mapping to match the requirements of the carrier. EDINotepad or similar application. The Express version is free and enables rendering, editing, and syntax validation of 834 format files. Available to download from: 5

6 What You Need to Know About the Third Party System What You Need to Know About the Third Party System The third party system receives the data from Fairsail. You must ensure that the extracted Fairsail data maps accurately to the requirements of the other system. Start by importing the Payflow Generic 834 Format File.fs, available on Box: You must amend this default format to match the requirements of the provider and of the customer. File specification for the third party system Consolidated Guide 834 Format is becoming the standard for benefit file transfers. The full specification document ASCX12 Benefit Enrollment and Maintenance (834) Consolidated Guide is: Available to buy from: This document is referred to as the Consolidated Guide in this Cookbook. Companion Guide Each provider typically produces a Companion Guide to their specific requirements for the format. See the example used for the Lewis implementation from Avesis Vision on Box: 6

7 What You Need to Know About the Third Party System Header and footer requirements Defined in the Download File Definition for the Payflow Service. You must change the generic settings supplied by the Generic 834 Format File.fs to match the requirements of the provider and of the customer. Use the Companion Guide from the provider. Refer to following pages in the Consolidated Guide. The document does not use conventional page numbering - enter the following page numbers in the PDF page number search: Header details o ISA codes o GS codes o 31 - ST codes o 32 - BGN codes o 37 - DTP codes o 41 - QTY codes o 44 - N1 codes Footer details o SE codes o GE codes o IEA codes Feed frequency and timing Testing process For many third party systems testing can be lengthy. Make sure the customer is aware of the potential impact on the implementation, and manage their expectations. Delivery Secure SFTP Pull mode is preferred: the data is requested from the Fairsail server by the third party system. Supply the Fairsail SFTP server details. Push mode: the data transfer is initiated by Fairsail and sent to the server for the third party system. Request the SFTP server details for the third party system. 7

8 Information From the Customer Information From the Customer Fairsail fields to map to the third party system The customer may not know all available fields; be prepared to help. Additional custom fields may be required. Translations For example, the third party system may need numeric codes for fields held as text on Fairsail: Relationship field holds the values Spouse, Partner, Child... Third party system may require 01, 02, New Starter Process Start date for benefits, for example: On sign up End of month Beginning of month Notice period required by the third party system for new starters. Terminations When do benefits expire for terminated employees? For example: On the termination date At the end of the month when they terminated A fixed period after termination Opting Out When does benefits cover expire for employees who opt out mid-term? For example: On the opt out date At the end of the month when they opted out A fixed period after opting out 8

9 Configuration Use the Generic 834 Format File.fs as a starting point and amend the configuration as required. Download Configure To configure the download: 1. On the Payflow Services Home page click the Name of the Service you want to configure. Fairsail displays the Payflow Service Console. 2. On the Payflow Service Console for the Service, click Configure. Fairsail displays the Configure page for the service. 3. In the Download Files section click Download Configure. Fairsail displays the Download Configure page. 4. Amend details to match the requirements given in the Companion Guide supplied by the benefit provider. 5. Complete other fields on the Download Configure page as necessary. Use the Payflow Implementer's Guide for reference. 6. Click Save. File Configure 1. On the Configure page for the service, in the Download Files section, click the Name of the file. Fairsail displays the Create Download File page for the file. 2. Change the name of the file as required. 3. Change Header and Footer details to match the requirements given in the Companion Guide supplied by the benefit provider. 4. Complete other fields on the Create Download File page as necessary. Use the Payflow Implementer's Guide for reference. 5. Click Save. 9

10 Configuration Field Mapping Field Mapping 834 Format uses the Position and Order fields to define the Loop in the file and the position of the field in the Loop: Position Order Defines the position of the field in the record, as defined by the requirements of the third party system. Defines the sequence in which fields are sorted in the record. Lower number orders appear earlier in the record than higher number orders. Fields are sorted by Order and then by Position. Edit Position and Order and field mapping details to match the requirements of the Companion Guide supplied by the provider. When you save each mapping, Fairsail redisplays the Create Download File page with the new mapping added to the list at the foot of the page. 10

11 Configuration Translations for Mapped Fields Translations for Mapped Fields 1. On the Create Download File page for the file, in the Mapping HCM to File section, click the Name of the mapped field. Fairsail displays the Configure page for the mapping. 2. At the bottom of the page in the Translations for this value section, click New. Fairsail displays the Configure Translation page: 3. In Current Value enter the value stored in Fairsail. 4. In Replacement enter the value to be used in the file for the third party. 5. Click Save. 6. For multiple values in the same field, repeat steps 2 to 5 as necessary to define the set of translations you want to apply. Translations for this value displays the translations you have loaded: 11

12 Index A About this Guide 4 C Configuration 9 D Download Configure 9 F Fairsail Payflow Implementer's Guide 4 Field Mapping 10 File Configure 9 H HIPAA 834 Benefits 5 I Information From the Customer 8 R Related Guides 4 Resources 5 T Translations for Mapped Fields 11 W What You Need to Know About the Third Party System 6 12