HIPAA EDI
Acknowledgements & Error Reporting
HIPAA Summit West II
March 13, 2002
San Francisco, CA
Presented by Rachel Foerster & Associates, Ltd.
Beach Park, IL 60099
847.872.8070 Fax: 847.872.6860
Email: rachel@rfa -edi.com
www.rfa-edi.com
Course HC-207 1
Discussion Topics
Ø EDI Envelopes and how they relate to EDI
acknowledgements
Ø The 4 Kinds of EDI acknowledgements
Ø Each acknowledgement’s purpose
Ø When to use each acknowledgment
Ø Issues for error reporting and acknowledging for
HIPAA EDI transactions
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Transmission Life Cycle of an EDI Document
Ø The processes an EDI
document passes
through on its journey
from the sender to the
receiver’s application
system
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EDI Envelopes
Ø Needed
§ to specify
• Recipient
• Sender
§ Keep contents intact
Ø Support auditing &
tracking
Ø Provide other critical
details
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Three Different EDI Envelopes
Document = Transaction Set
Department = Functional Group
Company = Interchange
Adjudication
Community Hospital
Small Town, IL
Big Payer
Any Town, IL
Claims
ISA/IEA
ST/SE
GS/GE
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Interchange Receipt Notification
Interchange
Health Care Provider Payer/Health Plan
Interchange Acknowledgment (TA1)
I got it!
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TA1 Interchange Acknowledgment
Ø Purpose
§ Reports the status of the interchange envelope only by
the receiver
• The successful receipt of the interchange
• The results of processing the interchange envelope
Very Similar to a Certified Mail Return Receipt
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Using the TA1
Ø Use is by trading partner agreement
§ HIPAA neither mandates or prohibits
Ø TA1 is a single segment
§ Transmitted without the GS/GE envelope
Ø Can be included in an interchange with other
functional groups and transactions
Ø Is not acknowledged by the receiver
Ø Reports status of the interchange envelope only
§ Not used to report the status of the functional groups and
transaction sets in the interchange
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Functional Group Acknowledgement
Interchange
ISA/IEA
Adjudication
Health Care Provider Payer/Health Plan
GS/GE
Functional Acknowledgment (TS997)
I got it, opened the
Claims
ST/SE
envelopes, and the
contents were ok/not ok.
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997 Functional Acknowledgment Transaction Set
Ø Purpose
§ To indicate the results of the syntactical analysis of
• Transaction sets
• Functional groups
• Verify and report compliance with the standard
§ Acknowledges receipt of an interchange
§ Reports acceptance/rejection of one or more
• Functional groups
• Transactions
Ø Does not cover
§ Semantic meaning of the information in the transaction sets
§ Compliance with the HIPAA implementation guide
DOES NOT CONFIRM APPLICATION PROCESSING
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Using the 997 Functional Acknowledgment
Ø Do not acknowledge a 997 FA
Ø 997 FA should not be sent to report errors in a previous
Functional Acknowledgment
Ø Functional Group Header Segment (GS) used to start the
envelope for the 997 FA
Ø Application sender’s code and application receiver’s code
from the functional group being acknowledged are
exchanged
§ one acknowledgment functional group responds to only
those functional groups from one application receiver’s code
to one application sender’s code
Ø Only one Functional Acknowledgment Transaction Set per
acknowledged functional group
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The 4 Levels of Acknowledgements & Notifications in
Health Care
Community Hospital
Small Town, IL
Big Payer
Any Town, IL
ISA/IEA
Adjudication
Claims
GS/GE ST/SE
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HIPAA IG Compliance Notification
Interchange
ISA/IEA
Health Care Provider Payer/Health Plan
HIPAA IG Compliance Notification (TS824)
Application Acknowledgment
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824 Application Advice Transaction Set
Ø Purpose
§ Report the results of an application system's data content edits
of transaction sets
§ Results can be reported at the functional group and
transaction set level
§ Designed to accommodate reporting the acceptance, rejection
or acceptance with change of any transaction set
§ Should not be used in place of a transaction set designed as a
specific response to another transaction set
• e.g., 270/271 – 276/277 – 278/278
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Using the 824 Application Advice
Transaction Set
Ø An implementation guide under development by
X12N/TG8 SPWG1 for reporting
§ Semantic compliance of a transaction against
• HIPAA implementation guide
• Other insurance transactions
§ Syntax compliance against an implementation guide
NOT A HIPAA MANDATED TRANSACTION
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Syntax vs Semantic
Ø Syntax: HIPAA IG compliance reported via 997
Valid code
Alphanumeric
Datatype
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Syntax vs Semantic
Ø Semantic: HIPAA IG compliance reported via 824
Valid Date Format
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Processing the TA1 & 997 Acknowledgements
Ø EDI Software should create
& process TA1 & 997
Ø Trading partners must
agree on use
§ Recommend policy of
always sending a 997 FA
• Report to lowest level, i.e.,
data element
§ Establish elapsed time for
expected receipt
§ Determine procedures for
non-receipt
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Processing the 824 IG Compliance
Acknowledgement
Ø EDI software available
today doesn’t automatically
create the 824
Ø Trading partners must still
agree on use
§ Establish elapsed time for
expected receipt
§ Determine procedures for
non-receipt
Ø No recommended
implementation guide
available for HIPAA
transactions
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Sufficient Control & Auditing
Ø Transaction cycle not complete if no application response
received
Ø Sufficient control & auditing provides all the information
needed to detect and resolve problems
§ TA1 advises receipt of interchange
§ 997 advises acceptance/rejection of functional groups &
transactions
§ 824 Application Advice advises compliance/non-compliance
of transaction with HIPAA IG
§ Application response transaction reports results of
application system edits and acceptance/rejection of
business data
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Other Challenges
Ø Tracking interchanges through multiple
intermediaries
§ TA3 can track an interchange through clearinghouses
• Not in the HIPAA implementation guides
Ø No common industry accepted business practice
for tracking & auditing electronic messages
Ø Some clearinghouses do not support the
X12/EDI controls
§ Use of Interchange sender/receiver Ids
§ Use of TA1/997
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A Complicated Model: Single Clearinghouse
Interchange Interchange
Clearinghouse
Interchange Acknowledgment (TA1) Interchange Acknowledgment (TA1)
Functional Acknowledgment (TS997) Functional Acknowledgment (TS997)
Application Acknowledgments Application Acknowledgments
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A Complex Model: Dual Clearinghouse
Interchange Interchange
Clearinghouse
Clearinghouse
Interchange Acknowledgment (TA1)
Functional Acknowledgment (TS997)
Application Acknowledgments
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TA3 Interchange Delivery Notice
Ø Purpose
§ Exchanged between service request handlers to inform
the sending service request handler of actions taken
on the interchange by the receiving service request
handler
§ Reports the delivery and the retrieval of the
interchange
§ Reports the unsuccessful delivery or retrieval of the
interchange and identifies the error condition
Ø Not described in HIPAA Guides
Ø No industry-accepted business use
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Use of the TA3 Interchange Delivery Notice
Ø Not described in HIPAA Guides
Ø No industry-accepted business use
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What’s Needed
Ø A well-defined model for the
§ Electronic message exchange business process
• Required business signals for
– Acknowledgments
– Exceptions
§ Routing, auditing & tracking of HIPAA transactions
Ø Agreement to use sufficient controls &
acknowledgments
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Contact Information
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