HIPAA TRANSACTION 837 PROFESSIONAL STANDARD COMPANION GUIDE

Transcription

1 HIPAA TRANSACTION 837 PROFESSIONAL STANDARD COMPANION GUIDE Refers to the Implementation Guides Based on X12 version A1 and version Companion Guide Version Number: 1.2 October 1, 2010

2 TABLE OF CONTENTS Table of Contents... 2 Disclosure Statement Introduction Scope Overview References Additional Information Getting Started Working with Office Ally, L.L.C Trading Partner Registration Certification and Testing Overview Testing with the Payer Connectivity with the Payer / Communications Process flows Transmission Administrative Procedures Communication protocol specifications Passwords Encryption Contact Information OA EDI Dept Page 2

3 6. ISA and GS Information Payer Specific Business Rules and Limitations Acknowledgements Trading Partner Agreements Appendices Business Associate / Trading Partners Agreement Transaction Specification Page 3

4 DISCLOSURE STATEMENT None specified. Office Ally L.L.C. will be referred to as OA through-out the balance of this document. PREFACE This Companion Document to the ASC X12N Implementation Guides adopted under HIPAA clarifies and specifies the data content when exchanging electronically with OA. Transmissions based on this companion document, used in tandem with the X12N Implementation Guides, are compliant with both X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. Page 4

5 1. INTRODUCTION 1.1 Scope This Companion document supports the implementation of a batch processing application. OA will accept inbound submissions that are formatted correctly in X12 terms version 4010A1. The files must comply with the specifications outlined in this companion document as well as the corresponding HIPAA implementation guide. OA will also be supporting the new version 5010 format. The compliance date for use of these standards is January 1, OA will be doing payer, partner, and provider testing and implementation sooner on a case by case basis. Please contact OA for details. OA EDI applications will edit for these formats and reject files that are out of compliance. This companion document will specify everything that is necessary to conduct EDI for this standard transaction. This includes: Specifications on the communications link Specifications on the submission methods Specifications on the transactions 1.2 Overview This companion guide compliments the ASC X12N implementation guide currently adopted from HIPAA. This companion guide will be the vehicle that OA uses with its trading partners to further qualify the HIPAA adopted implementation guide. This companion guide is compliant with the corresponding HIPAA implementation guide in terms of data element and code sets standards and requirements. Data elements that require mutual agreement and understanding will be specified in this companion guide. Types of information that will be clarified within this companion are: Qualifiers that will be used from the HIPAA implementation guides to describe certain data elements Situational segments and data elements that will be utilized to satisfy business conditions Trading partner profile information for purpose of establishing who we are trading with for the transmissions exchanged Page 5

6 1.3 References ASC X12N version 4010A1 Implementation Guides 1. Health Care Claim: Professional 837 (004010X098) May 2000 Guide 837 (004010X098A1) October 2002 Addenda 2. Health Care Claim: Institutional 837 (004010X096) May 2000 Guide 837 (004010X096A1) October 2002 Addenda 3. Health Care Claim: Dental 837 (004010X097) May 2000 Guide 837 (004010X097A1) October 2002 Addenda 4. Health Care Claim Payment/Advice 835 (004010X091) May 2000 Guide 835 (004010X091A1) October 2002 Addenda ASC X12N version 5010 Implementation Guides 5. Health Care Claim: Professional 837 (005010X222A1) Guide 6. Health Care Claim: Institutional 837 (005010X223A2) Guide 7. Health Care Claim: Dental 837 (005010X224A2) Guide 8. Health Care Claim Payment/Advice 835 (005010X221A1) Guide 1.4 Additional Information Electronic Data Interchange (EDI) is the computer-to-computer exchange of formatted business data between trading partners. The computer system generating the transactions must supply complete and accurate information while the system receiving the transactions must be capable of interpreting and utilizing the information in ASC X12N format, without human intervention. The transactions must be sent in a specific format that will allow our computer application to translate the data. OA supports the standard transactions adopted from HIPAA. OA maintains a dedicated staff for the purpose of enabling and processing X12 EDI transmissions with its trading partners. It is the goal of OA to establish trading partner relationships and to conduct EDI as opposed to paper information flows whenever and wherever possible. Page 6

7 2. GETTING STARTED 2.1 Working with Office Ally, L.L.C. Contact OA EDI Dept. for all EDI related customer service requests. (See contact information in section 5 below.) There are three units within OA that work internally to complete EDI service requests from our trading partners. The first unit is OA s EDI Operations Dept. This group will serve as the trading partner s central point of contact. This group will also facilitate the implementation of trading partners through all steps of external testing. The second unit is OA s IT infrastructure group. This is a technical team that implements the communication link and ensures that trading partner to payer connectivity is established properly. The third unit is OA s EDI IT Translator team. This group is responsible for our inbound and outbound X12 Translator applications. 2.2 Trading Partner Registration To register as a trading partner with OA the following sequence of events will take place. 1. Initial conversations are held between the trading partner and OA. 2. Verbal agreements are reached as to the transactions that will be conducted. 3. A trading partner agreement and associated companion guides are provided and reviewed. 4. A business associate agreement signed by both partners is required. 5. Required trading partner profiling is built into our EDI translator. 6. Test files are exchanged and test runs conducted. 7. Once the testing phase is completed and a trading partner agreement is in place the trading partner is moved to the production environment. 2.3 Certification and Testing Overview OA will show evidence of third party certification for the standard transactions. This is consistent with industry standard conventions that have been adopted for HIPAA Transaction and Code Sets implementation. This requirement exists so that the process to test and implement a trading partner for the purpose of conducting EDI with standard transactions is a smooth and efficient process. OA will be certified from EdiFecs incorporating the following WEDI/SNIP levels of testing where applicable: Page 7

8 Level 1, Integrity Testing (X12 Syntax) Level 2, Requirement Testing (HIPAA Implementation Guide Syntax) Level 3, Balancing Testing Level 4, Situation Testing (i.e. 835 claim line balancing to the claim document) (Use of Situational Segments that are business relevant) Level 5, Code Sets Testing Level 6, Product Types/Types of Service Testing (i.e. provider specialties) Page 8

9 3. TESTING WITH PAYER OA would like to establish with the trading partner a set of scenarios that are intended for testing. This can be a high level description of the contents of the transaction. This should be a representation or cross section of the majority of conditions that will be encountered with production data from these transactions. Page 9

10 4. CONNECTIVITY WITH THE PAYER / COMMUNICATIONS 4.1 Process flows Three file exchange methods are supported to enable batch data file transmission; (1) FTP of encrypted data over the Internet, (2) use of OA s secure Website, and (3) VPN for certain payers FTP of Encrypted data over the Internet One method of exchanging data files is encrypting the file, sending it over the Internet where it is then decrypted. For data inbound to Office Ally (see Figure 4.1.1A), the trading partner would encrypt the data on an internal server and then transfer to Office Ally s FTP server. Then, Office Ally will retrieve the encrypted file from the Office Ally FTP server to an internal server where the file is decrypted and processed. Figure 4.1.1A FTP of Encrypted Data over the Internet from Trading Partner to Office Ally Page 10

11 For data outbound from Office Ally (see Figure 4.1.1B), Office Ally will generate the X12 data file and encrypt it. Once encrypted, the file will be sent either to Office Ally FTP server or the trading partners FTP server. Then the trading partner can retrieve the file from the appropriate FTP server, transfer it to their internal system, decrypt the file and process. Figure 4.1.1B FTP of Encrypted Data over the Internet from Office Ally to Trading Partner Page 11

12 4.1.2 Use of Office Ally s secure website Data may also be exchanged via Office Ally s secure website (see Figure 4.1.2A). The transmission software is X-Upload. The trading partner must have a minimum of 128-bit cipher strength to utilize the website. For data inbound to Office Ally, the data file will be encrypted on the trading partners server prior to transmission. Office Ally will then transfer the encrypted file from the OA s web server to and internal server for decryption and processing. Data outbound from Office Ally takes the opposite path and remains on the web server encrypted until the trading partner retrieves the file and decrypts the file on their server. Data transferred over the Office Ally web site must be encrypted. Figure 4.1.2A Connect: Direct Transfer over the Office Ally Web site Page 12

13 4.1.3 VPN For trading partners that prefer to use a VPN, Office Ally supports this method of transmission.(see Figure 4.1.3A). Once established, data will be exchanged similarly to the FTP over the Internet approach except the data will not flow over the Internet. It is not necessary to encrypt data transferred over a VPN. Using a VPN is unidirectional. Figure 4.1.3A VPN Page 13

14 4.2 Transmission Administrative Procedures Before establishing data communications with Office Ally, a trading partner relationship must exist. As part of the process establishing the relationship, Office Ally and the trading partner must exchange certain technical information. This information is needed by both parties in order to establish communications. The information requested will include: 1. Contacts; business, data and communications 2. Dates; testing, production 3. File information; size, naming 4. Transfer; schedule, protocol 5. Server information; host name, userid, password, file location, file name 6. Notification; failure, success Re-transmission procedures When a file needs to be retransmitted, the trading partner will contact their primary contact at Office Ally. At that time, procedures will be followed for Office Ally to accept and re-transmit a file. 4.3 Communication protocol specifications FTP over the Internet The following items are required to exchange data with Office Ally utilizing FTP over the Internet. The trading partner is responsible for the acquisition and installation of these items. This list assumes that Office Ally FTP server will be used. 1. Internet Connectivity; if large files will be exchanged, then the trading partner should consider a broadband connection. 2. Computer with FTP client and connectivity to the Internet. 3. PGP software for encryption/decryption. RSA (also know as Legacy) keys must be generated and exchanged with Office Ally via (public keys only). 4. capability to exchange configuration and testing information. Initial setup will include confirming FTP connectivity, exchanging PGP public keys and performing end-toend communications testing. Before sending data to Office Ally, the data must be encrypted with PGP and then sent to the Office Ally FTP using the FTP client over the Internet connection. When receiving data from Office Ally, the FTP client will be used to get the data from the Office Ally FTP server after which PGP will be used to decrypt the data. Page 14

15 4.3.2 Office Ally s secure Website The following items are required to exchange data with Office Ally utilizing the secure website. 1. Internet Connectivity; if large files will be exchanged, then the trading partner should consider a broadband connection. 2. Minimum 128-bit cipher strength for encryption. 3. Office Ally will download X-upload to client box during first log in. 4. A user id and password for access to the Office Ally website. 5. capability to exchange configuration and testing information. Initial setup will include the exchange of test files to ensure end-to-end communication. Using the Office Ally website is bi-directional. The trading partner initiates the connection for both uploads and downloads of files VPN Connection The following items are required to exchange data with Office Ally utilizing VPN. 1. Connectivity via a modem. 2. Internal VPN. 3. It is not necessary to encrypt files transferred over a VPN. 4. capability to exchange configuration and testing information. Initial setup will include the exchange of User ids and passwords. 4.4 Passwords Office Ally requires the use of User IDs and Passwords to access its systems and servers. If Office Ally s FTP server is to be used to exchange data, Office Ally will assign each trading partner a unique userid and password. The UserID and other information will be communicated with the trading partner via . However, the password will be communicated via another method such as phone or fax. In the event a trading partner forgets their password, Office Ally will change the password after verifying the authenticity of the requestor. Office Ally will not utilize a trading partner owned FTP server that is not protected with a userid and password. 4.5 Encryption Office Ally requires the encryption of data that is exchanged via the Internet or any other public network. Office Ally utilizes PGP with 1024 or 2048 bit keys for file encryption. For web-based transmissions Office Ally utilizes 128-bit cipher strength and X-upload for encrypted transmissions via the web. Page 15

16 5 CONTACT INFORMATION 5.1 OA EDI Dept OA EDI Dept. is the central point of contact for all trading partner EDI activity including questions relating to file submissions. OA EDI Dept. will internally route EDI questions to one of three EDI areas for resolution. Once resolution is reached trading partners will receive a response from this same central EDI Dept. The three areas within OA EDI that work on EDI customer service issues are; OA EDI Translator Team OA Payer Connectivity and Infrastructure Team OA EDI Business Operations Team Contact Names and Titles: To be provided Contact Phone number for EDI Dept is Page 16

17 6. ISA AND GS INFORMATION This section describes OA use of the interchange (ISA) and functional group (GS) control segments. Note that submissions to Office Ally are limited to one interchange (ISA) and one functional group (GS) per file. Files may contain up to 5000 transaction sets (ST). 837 INBOUND TRANSACTION X12 Data Description Values Used Comments Element ISA01 Authorization NA NA Qualifier ISA02 Authorization Code NA NA ISA03 Security Qualifier NA NA ISA04 Security Information NA NA ISA05 Sender Qualifier ISA06 Sender Id Trading Partner s Sender Id Tax Id is preferred ISA07 Receiver Qualifier ISA08 Receiver Id Office Ally Tax Id ISA11 (4010) Interchange Control U Standards ID ISA11 (5010) Repetition Separator ^ or your repetition separator ISA12 Interchange Control Version Num for 4010, for 5010 ISA15 Usage Indicator T P Test File Production File GS01 Functional Id Code Indicates transaction type See HIPAA IG GS02 Sender s Code Trading Partner s Sender Code No Suggestions GS03 Receiver s Code OA OA Business Units identified for translator routing purposes. GS08 Version Release Industry ID Code Identifies the transaction in ASC Terms See HIPAA IG Page 17

18 7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS Numeric fields should be right justified and zero filled Alphanumeric fields should be left justified and space filled All monetary amounts are to include decimal points with two positions allowed to the right of the decimal point to represent cents. Page 18

19 8. ACKNOWLEDGEMENTS 997 Acknowledgement will be sent so the trading partner will get confirmation that we received their 837 submission. Page 19

20 9. TRADING PARTNER AGREEMENTS OA requires a trading partner agreement be signed before any exchange of data can occur. Page 20

21 10. APPENDICES This section contains one or more appendices. An Implementation Checklist Trading Partner Testing Check List The following tasks should be completed to insure a smooth implementation of the EDI process. TASK Establish ISA and GS information Determine Communication Mode Execute Trading Partner Agreement Confirm Business rules If required, set-up encryption process Establish schedule for testing Complete testing Production cut-over Responsibilit y OA & TP OA & TP OA & TP OA & TP OA & TP OA & TP OA & TP OA & TP Date Page 21

22 11. BUSINESS ASSOCIATE / TRADING PARTNER AGREEMENT This Business Associate Agreement ( Agreement ) by and between (hereinafter known as Business Associate ) and Office Ally, LLC. (hereinafter known as Covered Entity ), and is effective as of,,. Covered Entity and Business Associate shall collectively be known herein as the Parties. WHEREAS, Covered Entity wishes to commence a business relationship with Business Associate whereby Business Associate will provide products and services to Covered Entity pursuant to a separate services agreement; WHEREAS, the nature of the prospective contractual relationship between Covered Entity and Business Associates may involve the exchange of Protected Health Information ( PHI ) or Electronic Protected Health Information ( ephi ) as those terms are defined under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), including all pertinent regulations issued by the Department of Health and Human Services ( HHS ); WHEREAS, Covered Entity and Business Associate intend to protect the privacy and provide the security of PHI and/or ephi disclosed to Business Associate in compliance with the Privacy and Security Rule. NOW THEREFORE, in consideration of the mutual promises below and the exchange of information pursuant to this Agreement, the parties agree as follows. A. DEFINITIONS 1. Breach means the unauthorized acquisition, access, use or disclosure of PHI without regard to whether such access, use or disclosure compromises the security or privacy of the PHI such that the Breach poses a significant risk of financial, reputational, or other harm to the individual, as provided in the 45 CFR Business Associate shall have the same meaning as given in 45 CFR Covered Entity shall have the same meaning as given in 45 CFR Discovery shall mean the first day on which a Breach is known to Business Associate (including any person, other than the individual committing the breach, that is an employee officer, or other agent of Business Associate), or should reasonably have been known to Business Associate (or person), to have occurred. 5. HIPAA or Health Insurance Portability and Accountability Act of 1996 is the law under which the Privacy and Security Rules were promulgated. 6. HITECH Act or Health Information Technology for Economic and Clinical Health Act are those provisions set forth in Title XIII of Public Law as enacted on February 17, Page 22

23 7. Individual shall have the same meaning as the term individual in 45 CFR and shall include a person who qualifies as a personal representative in accordance with 45 CFR (g). 8. Privacy Rule is the regulation entitled Standards for Privacy of Individually Identifiable Health Information, promulgated under HIPAA and/or the HITECH Act that is codified at 45 CFR part 160 and 164, Subparts A, D, and E. 9. Protected Health Information ( PHI ) and Electronic Protected health Information ( ephi ) shall have the meaning given to such terms as 45 CFR Required By Law shall have the same meaning as the term required by law in 45 CFR Security Rule is the regulation entitled Security Standards for the Protection of Electronic Protected Health Information, promulgated under HIPAA and/or the HITECH Act that is codified at 45 CFR, parts 160 and 164, subparts A,C, and D. 12. Secretary shall have the same meaning as given in 45 CFR Protected Health Information or PHI shall have the same meaning as given in 45 CFR , limited to the information created or received by Business Associate from or on behalf of Covered Entity. 14. Unsecured Protected Health Information means Protected Health Information that is not secured through the use of a technology or methodology specified by guidance issued by the Secretary from time to time. B. OBLIGATIONS OF BUSINESS ASSOCIATE a. Limitation(s) on Uses and Disclosures. Business Associate agrees to not use or disclose PHI or ephi other than as permitted or required by this Agreement or as Required by Law. Business Associate s use and disclosure of PHI or ephi is strictly limited to those instances where it is necessary to the performance of duties contractually delegated to it by Covered Entity in a separate services agreement or as Required By Law. Business Associate shall also comply with any further limitations on uses and disclosures agreed to by Covered Entity in accordance with 45 CFR , provided that such agreed upon limitations have been communicated to Business Associate, may use or disclose Protected Covered Entity as specified in any written agreement between the parties, provided that such use or disclosure would not violate the Privacy Rule if done by Covered Entity or the minimum policies and procedures of the Covered Entity. b. Permitted Uses and Disclosures. Business Associate may use and disclose PHI and/or ephi created or received pursuant to this agreement as follows: i. To carry out the purposes of this Agreement. Business Associate may use and disclose Covered Entity s PHI and/or ephi received or created by Business Associate (or its agents and subcontractors) in performing its obligations pursuant to this Agreement. ii. For Archival purposes. Page 23

24 iii. iv. Use for Management and Administration. Business Associate may use PHI and/or ephi created or received in its capacity as a Business Associate of Covered Entity for the proper management and administration of Business Associate, if such use is necessary (i) for the proper management and administration of Business Associate or (ii) to carry out the legal responsibilities of Business Associate. Disclosure for Management and Administration. Business Associate may disclose PHI and/or ephi created or received in its capacity as a Business Associate of Covered Entity for the proper management and administration of Business Associate if (i) the disclosure is Required by Law or (ii) Business Associate (a) obtains reasonable assurances from the person to whom the PHI and/or ephi is disclosed that it will be held confidentially and used or further disclosed only as Required by Law or for the purpose for which it was disclosed to the person and (b) the person agrees to notify Business Associate of any instances of which it becomes aware in which the confidentiality and security of the PHI and/or ephi has been breached. v. Data Aggregation Services. Business Associate may aggregate the PHI and/or ephi created or received pursuant this Agreement with the PHI and/or ephi of other covered entities that Business Associate has in its possession through its capacity as a Business Associate of such covered entities for the purpose of providing Covered Entity with data analyses relating to the health care operations of Covered Entity (as defined in 45 C.F.R ). vi. De-Identification of PHI and/or ephi. Business Associate may de-identify any and all PHI and/or ephi received or created pursuant to this Agreement, provided that the de-identification process conforms to the requirements of 45 CFR (b). c. Nondisclosure. Business Associate shall not use or further disclose Covered Entity s PHI and/or ephi otherwise than permitted or required by this Agreement or as Required by Law. d. Safeguards. Business Associate shall use appropriate administrative, physical, and technical safeguards, including, among others, policies and procedures regarding the protection of PHI and/or ephi and the provisions of training on such policies and procedures to applicable employees, independent contractors and volunteers, that reasonably and appropriately protect the confidentiality, integrity, and availability of the PHI and/or ephi that Business Associate creates, receives, maintains or transmits on behalf of Covered Entity. i. With respect to ephi, Business Associate shall implement and comply with (and ensure that its subcontractors implement and comply with) the administrative safeguards set forth at 45 CFR , the physical safeguards set forth at 45 CFR , the technical safeguards set forth at 45 CFR , and the policies and procedures set forth at 45 CFR to reasonably and appropriately protect the confidentiality, integrity, and availability of the ephi that it creates, receives, maintains, or transmits on behalf of Covered Entity. Business Associate acknowledges that, effective the later of Effective Date of this Agreement or February 17, 2010, (a) the foregoing safeguards, policies and procedures requirements shall apply to Business Associate in the same manner that such requirements apply to Covered Entity, and (b) Business Associate may be liable under the civil and criminal enforcement provisions set forth at 42 U.S.C. 1320d-5 and 1320d-6, as Page 24

25 amended form time to time, for failure to comply with the safeguards, policies and procedures requirements and any guidance issued by the Secretary from time to time with respect to such requirements. ii. With respect to ephi, Business Associate shall ensure that any agent, including a subcontractor, to whom it provides ephi, agrees to implement reasonable and appropriate safeguards to protect it. e. Reporting of Breaches. Except as specifically provided in subsection (d)(ii), Business Associate agrees to report to Covered Entity any Breach of Unsecured PHI without unreasonable delay and in no such case later than ten (10) calendar days after Discovery of a Breach. Such notice shall include the identification of each individual whose Unsecured PHI has been or is reasonably believed by Business Associate to have been accessed, acquired, used or disclosed in connection with such Breach. In addition, Business Associate shall provide any additional information reasonable requested by Covered Entity for purposes of investigating and responding to the Breach. Notification of Breach or potential Breach under this Agreement shall be made to Covered Entity as indicated in section X part d. i. Determination of Significant Risk. Business Associate specifically agrees that it shall be the Covered Entity s right and responsibility to determine whether a Breach compromises the security or privacy of the PHI such that the Brach poses a significant risk of financial, reputational, or other harm to the individual. ii. Exceptions to Reporting Obligation. Business Associate shall not be required to report an individual Breach to covered Entity that is described in this subparagraph ii as follows: a. The unintentional acquisition, access, or use of PHI by a workforce member or person acting under the authority of the Business Associate, if such acquisition, access, or use was made in good faith and within the scope of authority granted by such Business Associate and does not result in further acquisition, access, use or disclosure in a manner not permitted under the Privacy Rule. b. Any inadvertent disclosure by a person who is authorized to access PHI at Business Associate to another person authorized to access PHI at Business Associate, and the information received as a result of such disclosure is not further acquired, accessed, used or disclosed in a manner not permitted under the Privacy Rule. c. Any disclosure of PHI where he Covered Entity or Business Associate has a good faith belief that an unauthorized person to whom the disclosure was made would not reasonable have been able to retain such information. Business Associate shall retain the documentation required by this subparagraph ii and shall make it available to Covered Entity upon request as appropriate in a format as mutually agreed between the parties. Business Associate shall provide Covered Entity with any further information or documentation that Covered Entity requests related to such Breach. f. Additional Responsibilities in the Event of Breach. Business Associate shall take prompt steps to limit or avoid the recurrence of any Security Breach, and take any other action pertaining to such unauthorized access or disclosure required by applicable federal and state laws and regulations. Business Associate must comply with this provision regardless of any actions taken by Covered Entity. Business Associate further Page 25

26 agrees to mitigate, to the extent practicable, any harmful effect that becomes known to Business Associate as a result of a Breach or use or disclosure or PHI by Business Associate in violation of the requirements of this Agreement. g. Use of Agents and Subcontractors. Business Associate shall ensure that any of its agents and subcontractors to whom it provides PHI and/or ephi created or received pursuant to this Agreement agrees to the same restrictions, conditions and safeguards that apply to Business Associate pursuant to this Agreement with respect to such PHI and/or ephi. With respect to the obligations of Sections II.e and IIf. hereof, Business Associate represents that any agent or subcontractor shall be obligated to notify Business Associate of any Breach within 10 calendar days in the same manner and according to the same terms and provided herein. In no event shall Subcontractor, without Covered Entities prior written approval, provide PHI received from, or created or received by Business Associate on behalf of Covered Entity, to any employee or agent, including a subcontractor, if such employee, agent or subcontractor receives, processes or otherwise has access to PHI outside of the United States. h. Availability of Information to Covered Entity. Within five (5) business days of receipt of a request from Covered Entity, Business Associate shall make available to Covered Entity such information as Covered Entity may require to fulfill Covered Entity s obligation to provide access to, and a copy of, PHI and/or ephi pursuant to this Agreement in accordance with the Privacy Rule, including but not limited to 45 C.F.R If an Individual requests such information directly from Business Associate, Business Associate must notify Covered Entity in writing within five (5) business days. Business Associate shall not give the Individual access to the information unless access is approved by Covered Entity. Covered Entity shall have full discretion to determine whether the Individual shall be given access. i. Amendment of PHI. Within five (5) business days of receipt of a request from Covered Entity, Business Associate shall make Covered Entity s PHI and/or ephi available to Covered Entity so that Covered Entity may fulfill its obligations to amend such PHI and/or ephi pursuant to the Privacy Rule, including but not limited to, 45 C.F.R Business Associate shall incorporate any amendments to any Covered Entity s PHI and/or ephi maintained by Business Associate. j. Accounting of PHI. Within five (5) business days notice by Covered Entity of a request for an accounting of disclosures of PHI, Business Associate shall make available the PHI, including ephi, to Covered Entity as required for Covered Entity to fulfill its obligations to provide an accounting pursuant to the Privacy Rule, including but not limited to, 45 C.F.R Business Associate shall implement a process that allows for such an accounting. k. Availability of Books and Records. Business Associate shall make its internal practices, books and records relating to the use and disclosure of PHI, including ephi, created or received pursuant to this Agreement available to the Secretary of the United States Department of Health and Human Services, for the purpose of determining Covered Entity s compliance with the Privacy and Security Rules as set forth in 45 C.F.R l. Record Retention. Subject to section 5 below, Business Associate shall retain all PHI and or/ephi received from Covered Entity, or created or received in the course of performing its obligations, for the duration of the term of this Agreement. Page 26

27 m. Minimum Necessary Amount of PHI. Business Associate acknowledges that it shall request from Covered Entity and so disclose to its affiliates, agents and subcontractors or other authorized third parties, only (i) the information contained in a limited data set, as such term is defined at 45 C.F.R (e) (2), or, (ii) if needed by Business Associate or its affiliates, agents, subcontractors or other authorized third parties, to the minimum necessary data to accomplish the intended purpose of such requests or disclosures. In all cases, Business Associate shall request and disclose PHI only in a manner that is consistent with guidance issued by the Secretary from time to time. n. Standard Transactions. If Business Associate conducts any Standard Transactions on behalf of Covered Entity, Business Associate shall comply with the applicable requirements of 45 C.F.R. Parts o. Data Ownership. Business Associate acknowledges that Covered Entity is the owner of all PHI and/or ephi. p. Mutual Indemnification. Each party ( the Indemnifying Party ) shall indemnify and hold harmless the other party (the Indemnified Party ) including any of the Indemnified Party s affiliates, directors, officers, employees and agents from and against any claim, cause of action, liability, damage, cost or expense (including reasonable attorney s fees) arising out of or relating to any Breach or other non-permitted use or disclosure of PHI or ephi, failure to safeguard PHI or ephi, or other breach of this Agreement by the Indemnifying Party of any of the Indemnifying Party s affiliates, directors, officers, employees, agents or subcontractors. Furthermore, any specific listing of duties or functions to be performed by Business Associate for Covered Entity contained in a separate contract (or addendum thereto) between the Parties is hereby incorporated by reference into this agreement for the sole purpose of further elaborating duties and functions that Business Associate is contractually undertaking on behalf of the Covered Entity. In all instances, Business Associate shall not use or disclose PHI and/or ephi obtained from Covered Entity in a manner that would violate the Security and Privacy Rule of HIPAA, the HITECH Act or the pertinent regulations of HHS. C. OBLIGATIONS OF COVERED ENTITY a. Notice of Privacy Practices. Covered Entity shall notify Business Associate of any limitation(s) in Covered Entity s notice of privacy practices that are produced in accordance with 45 C.F.R (as well as any changes to that notice), to the extent that such limitation(s) may affect Business Associate s use or disclosure of Protected Health Information. b. Revocation of Authorization. Covered Entity shall provide Business Associate with any changes in, or revocation of, permission by Individual to use or disclose Protected Health Information, to the extent that such changes affect Business Associate s use or disclosure of PHI. c. Restrictions. Covered Entity shall notify Business Associate of any restriction to the use or discloser of PHI that Covered Entity has agreed to in accordance with 45 C.F.R , to the extent that such restriction may affect Business Associate s use or disclosure of PHI. Page 27

28 D. AUDITS, INSPECTION AND ENFORCEMENT Covered Entity, after providing ten (10) business days written notice, may inspect the facilities, systems, books, records, agreements, policies and procedures relating to the use or disclosure of PHI pursuant to this Agreement for the purpose of determining whether the Business Associate has complied with this Agreement E. TERM AND TERMINATION a. Term. The Term of this Agreement shall be effective as of the compliance date set out in applicable Regulations, and subject to any extension obtained by either party or granted under the Regulations; and shall terminate when all of the PHI provided by Covered Entity to Business Associate, or created or received by Business Associate on behalf of Covered Entity, is destroyed or returned to Covered Entity, or, if it is infeasible to return or destroy PHI, protections are extended to such information in accordance with the termination provisions in this Section. b. Termination for Cause. Upon Covered Entity s knowledge of a material breach by Business Associate, Covered Entity shall either: i. Provide an opportunity for Business Associate to cure the breach or end the violation and terminate this Agreement if Business Associate does not cure the breach or end the violation within the time specified by Covered Entity; ii. Immediately terminate this Agreement if Business Associate has breached a material term of this Agreement and cure is not possible; or iii. If neither termination nor cure is feasible, Covered Entity shall report the violation to the Secretary. c. Effect of Termination. i. Except as provided in paragraph (c)(ii) of this section, upon termination of this Agreement, for any reason, Business Associate shall return or destroy all PHI received from Covered Entity, or created or received by Business Associate on behalf of the Covered Entity at the end of 7 years. This provision shall apply to PHI that is in the possession of subcontractors or agents of Business Associate. Business Associate shall retain no copies of the PHI. ii. In the event that Business Associate determines that returning or destroying the PHI is infeasible, Business Associate shall provide to Covered Entity written notification of the conditions that make return or destruction infeasible. After written notification that return or destruction of PHI is infeasible, Business Associate shall extend the protections of this Agreement to such PHI and limit further uses and disclosure of such PHI to those purposes that make the return or destruction infeasible, for so long as Business Associate maintain such PHI. iii. Right of Termination of Existing Service Contracts. Should Business Associate make a disclosure of PHI in violation of this Agreement, Covered Entity shall have the right to immediately terminate any contract, other than this Agreement, then in force between the Parties. Page 28

29 VI. DISCLAIMER Business Associate makes no warranty or representation that compliance by Covered Entity with this Agreement, HIPAA, the HITECH Act, or the Privacy and Security Rules will be adequate or satisfactory for Covered Entity s own purposes. Covered Entity is solely responsible for all decisions made by Covered Entity regarding the safeguards of PHI and/or ephi. VII. NO THIRD PARTY BENEFICIARIES Nothing express or implied in this Agreement is intended to confer, nor shall anything herein confer, upon any person other than Covered Entity, Business Associate and their respective successors and assigns, any rights, remedies, obligations or liabilities whatsoever. VIII. CHANGE IN APPLICABLE LAWS OR REGULATIONS In the event the laws or regulations of the United States or the State in which the majority of services are rendered are modified or amended in any material way with respect to this Agreement, this Agreement shall not be terminated but rather, to the extent feasible, shall be promptly amended by the parties to operating in compliance with the existing law. The parties acknowledge that their responsibilities under this Agreement may be affected and governed by the requirements of HIPAA and/or the HITECH Act, to the extent that regulations implementing HIPAA and/or the HITECH Act (the Regulations ) become effective during the Term of this Agreement or any renewal thereof. Both parties agree that, upon the effective date of any such obligations applicable to each of them under such Regulations pursuant to their responsibilities hereunder. To the extent any amendments to this Agreement shall be necessary to effectuate of clarify the obligations of the parties pursuant to such Regulations, the parties hereby agree to negotiate such amendments in good faith, subject to the right of either party to terminate this Agreement in accordance with its terms. IX. REMEDIES IN THE EVENT OF A BREACH Business Associate hereby recognizes that irreparable harm will result to Covered Entity, and to the business of Covered Entity, in the event of breach by Business Associate of any of the covenants and assurances contained in Section II of this Agreement. As such, in the event of breach of any of the covenants and assurances contained in Section II above, Covered Entity shall be entitled to enjoin and restrain Business Associate from any continued violation of Section II. Furthermore, in the event of breach of Section II by Business Associate, Covered Entity will be entitled to reimbursement and indemnification from Business Associate for the Covered Entity s reasonable attorneys fees and expenses and costs that were reasonable incurred as a proximate result of the Business Associate s breach. The remedies in this Paragraph G shall be in addition to (and not to supersede) any action for damages Covered Entity may have for breach of any part of this Agreement. X. MODIFICATION This Agreement may only be modified through a writing signed by the Parties and, thus, no oral modification hereof shall be permitted. The Parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for Covered Entity to comply with the requirements of the Privacy Rule and the Health Insurance Portability and Accountability Act of 1996, Pub. L. No Page 29

30 XI. INTERPRETATION Should there be any conflict between the language of this contract and any other contract entered into between the Parties (either previous or subsequent to the date of this Agreement), the language and provisions of this Agreement shall control and prevail unless in a subsequent written agreement the Parties specifically refer to this Agreement by its title and date, and, also, specifically state that the provisions of the later written agreement shall control over this Agreement. Any ambiguity in this Agreement shall be resolved in favor of a meaning that permits Covered Entity and Business Associate to comply with the Privacy and Security Rules and/or the HITECH Act. XII. MISCELLANEOUS a. Nothing n this Agreement shall be construed as an admission on the part of either Party that the relationship between the Covered Entity and the Business Associate is one of Covered Entity and Business Associate as those terms are known and construed under HIPAA, the HITECH Act, and pertinent regulations issued by the Secretary. However, the duties and obligations of Business Associate under this agreement remain in full force and effect regardless of whether or not the relationship between the Parties is determined to be one between a Covered Entity and a Business Associate as those terms are known and construed under HIPAA, the HITECH Act, and pertinent regulations issued by the Secretary. b. Any ambiguity in this Agreement shall be resolved to permit Covered Entity and Business Associate to comply with HIPAA, the HITECH Act and the Security and Privacy Rule. c. Regulatory References. A reference in this Agreement to a section in the Privacy Rule means the section as in effect or amended. d. Notice to Covered Entity or Business Associate. Any notice required under this Agreement to be given to Covered Entity or Business Associate shall be made in writing to: COVERED ENTITY BUSINESS ASSOCIATE Practice Information Name Street Address City/State/Zip Code Phone Number Brian O Neill Name President & CEO Title PO Box Street Address Vancouver, WA City/State/Zip Code Phone Number Page 30

31 IN WITNESS WHEREOF and acknowledging acceptance and agreement of the foregoing, the Parties affix their signatures hereto. Covered Entity Name, Title Signature Date: Business Associate Brian P. O Neill Name, Title Signature Date: PLEASE KEEP A COPY FOR YOUR RECORDS. PLEASE FAX A COPY TO: (360) PLEASE FAX A COPY Page 31

32 12. TRANSACTION SPECIFICATION Please note: This companion guide lists Legacy Numbers as optional, although they may be required by certain payers until the end of the dual usage period (May 23, 2008). Refer to the payer s contingency plan documentation for more information. Beginning Hierarchical Transaction Loop Id Submitter Name Segment Id Reference Designator Values BHT BHT06 CH RP REF REF X98A X98DA1 Descriptions Claims Submissions Encounters Submissions 4010 Production File 4010 Test File (not used in 5010) Loop Id Segment Id Reference Designator Values Descriptions 1000A NM1 NM ETIN 1000A NM1 NM109 TBD Submitter Id 1000A PER PER02 TBD Submitter Contact Name 1000A PER PER04 TBD Submitter Contact Phone No. Receiver Name Loop Id Segment Id Reference Designator Values Descriptions 1000B NM1 NM ETIN 1000B NM1 NM Receiver Id (OA Tax Id) Billing Provider Name Loop Id Segment Id Reference Designator Values Descriptions 2010AA NM1 NM108 XX Qualifier 2010AA NM1 NM109 Billing NPI 2010AA REF REF01 EI or SY Billing Tax ID or SSN Qualifier 2010AA REF REF02 Billing Tax ID or SSN Page 32

33 Optional 2010AA REF REF01 Select Appropriate Qualifier Qualifier 2010AA REF REF02 Legacy Billing Provider Number Pay-To Provider Name Loop Id Segment Reference Designator Values Descriptions Id 2010AB NM1 NM108 (4010 only) XX Qualifier 2010AB NM1 NM109 (4010 only) Pay To Provider NPI 2010AB NM only No new name is allowed, Only an address (see spec) 2010AB REF REF01 (4010 only) EI or SY Qualifier 2010AB REF REF02 (4010 only) Pay to Tax ID or SSN Optional 2010AB REF REF01 (4010 only) Select Qualifier Appropriate Qualifier 2010AB REF REF02 (4010 only) Legacy Pay to Provider Number Subscriber Name Loop Id Segment Id Reference Designator Values Descriptions 2010BA NM1 NM108 MI Qualifier 2010BA NM1 NM109 Subscriber Id Payer Name Loop Id Segment Id Reference Designator Values Descriptions 2010BB NM1 NM109 Payer Id Patient Name Loop Id Segment Id Reference Designator Values Descriptions 2010CA NM1 NM108 MI Qualifier 2010CA NM1 NM109 Patient Id from Id Card Page 33

34 Referring Provider Name (Claim Loops) Loop Id Segment Id Reference Designator Values Descriptions 2310A NM1 NM108 XX Qualifier 2310A NM1 NM109 Referring NPI Optional 2310A REF REF01 1G UPIN Qualifier 2310A REF REF02 UPIN Rendering Provider Name (Claim Loops) Loop Id Segment Reference Designator Values Descriptions Id 2310B NM1 NM108 XX Qualifier 2310B NM1 NM109 Rendering NPI 2310B REF REF01 (4010 only) EI or SY Qualifier 2310B REF REF02 (4010 only Rendering Tax ID or SSN Optional 2310B REF REF01 Select Qualifier Appropriate Qualifier 2310B REF REF02 Legacy Rendering Provider Number Service Facility Location (Claim Loops) Loop Id Segment Id Reference Designator Values Descriptions 2310D NM1 NM108 XX Qualifier 2310D NM1 NM109 NPI Facility Optional 2310D REF REF01 Select Appropriate Qualifier Qualifier 2310D REF REF02 Legacy Facility ID Page 34

35 Supervising Provider Name (Claim Loops) Loop Id Segment Id Reference Designator Values Descriptions 2310E NM1 NM108 XX Qualifier 2310E NM1 NM109 Supervising Provider Tax Id Optional 2310E REF REF01 Select Appropriate Qualifier Qualifier 2310E REF REF02 Legacy Supervising Provider Number Ordering Provider Name (Line Loop) Loop Id Segment Id Reference Designator Values Descriptions 2420E NM1 NM108 XX Qualifier 2420E NM1 NM109 Ordering Provider NPI Optional 2420E REF REF01 Select Appropriate Qualifier Qualifier 2420E REF REF02 Legacy Ordering Provider Number Page 35