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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