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Chapter 2: Running HIPAA Transaction Manager [Table of Contents] Configuring HIPAA Transaction Manager

HIPAA Transaction Manager User's Guide

[-] Chapter 2: Running HIPAA Transaction Manager
[-] How HIPAA Transaction Manager works

How HIPAA Transaction Manager works

Figure 2-1 illustrates how you can use HIPAA Transaction Manager's splitting and merging functionality within a customized workflow. Your actual implementation of HIPAA Transaction Manager may be more or less complex.

A detailed description of the workflow follows the diagram and introduces HIPAA Transaction Manager's split and merge concepts. See "Primary flow" and "Recovery flow".

Figure 2-1: Using HIPAA Transaction Managerraster

Primary flow

In the Primary Flow (activity above the dotted line), the following processes occur:

  1. An X12 data file is received, where it runs through HIPAA Implementation Guide compliance maps. See "Recovery flow" for data that fails HIPAA compliance.

  2. The 997 Functional Acknowledgement and optional TA1 segments are generated so the originator of the data can receive a status on how the X12 data processed through the HIPAA compliance maps.

  3. Transactions that pass HIPAA compliance run through translation maps and then pass to the claims adjudication process.

Recovery flow

In the Recovery Flow (activity below the dotted line), the following process applies to data that fails the initial HIPAA compliance validation tests:

  1. Data that fails HIPAA compliance testing is reprocessed through less stringent compliance maps that assure structural compliance with HIPAA transactions. Non-structurally compliant data is rejected as before, at the transaction level, while structurally compliant data is then processed further to recover compliant claims that were rejected because they were bundled into the same transaction with one or more noncompliant claims.

    The HIPAA Implementation Guide and HIPAA Structural Compliance Maps both produce accepted and rejected transactions. How you process those transactions internally and, optionally, to your trading partner, is a business workflow decision.

  2. All X12 transactions that pass Step 1are split into individual transactions containing one and only one claim each.

  3. The split transactions process through HIPAA compliance maps again.

  4. Noncompliant (bad) transactions are rejected to an output folder.

  5. Compliant (good) claims that pass HIPAA validation can be passed directly to the translator or optionally merged for translation.

  6. The results of the second run of HIPAA compliance validation can be reported back to the originator of the data through a 997 Functional Acknowledgement.

The HIPAA Structural Compliance Maps, shown in the Recovery Flow of Figure 2-1, are to be provided separately in a future HIPAA Accelerator release. Contact Sybase Technical Support if you need maps in the interim.

HIPAA Transaction Manager's input requirements

At a minimum, the following types of errors must be filtered out of data that HIPAA Transaction Manager processes. Any one of these errors should cause the entire transaction to be rejected:

Splitting transactions

HIPAA Transaction Manager's split command unbundles or splits every claim between the ST-SE segment into a single business document, which is contained in a separate ISA-IEA envelope. That is, the appropriate header, provider, subscriber, and dependent information is included for each new business document created. In an 837 transaction, the split would occur at the CLM segment:

ISA
    GS
        ST
        ...
            CLM1
            CLM2
            ...
        SE
    GE
IEA 

The control segments in each new ISA-IEA repeat individual Interchange (ISA-IEA), Group (GS-GE), and Transaction (ST-SE) control segments from the original interchange.

The input to the split command can comprise one or more files. Similarly, output can be one or more files, where each output file contains one and only one interchange containing one and only one business document, such as a claim.

X12 data input can be either accessed from disk or from memory. Similarly, the X12 data output can be stored to disk or in memory. If data is accessed from or written to disk, the inputs/outputs can be a disk file or multiple disk files in one directory. If data is accessed from or written to memory, the inputs/outputs are stored as string arrays.

When running maps through ECMap/ECRTP, an option exists for mailboxing. Based on the setup you assigned, the good and bad data are routed to specific folders. For example, if a transaction fails the HIPAA Structured Compliance Maps while running maps through ECMap/ECRTP, the transaction will be sent to the "bad" folder you assigned.

Splitting levels

HIPAA Transaction Manager splits each of the transactions at specific points. For example, to support the CMS mandate, the 837D, 837I and 837P all split transactions at the claim level (CLM). The following table illustrates the split levels for each of the HIPAA transactions.

Transaction

Segment

Level

270

EQ

Eligibility or Benefit Inquiry

271

EB

Eligibility or Benefit Information

276

TRN

Claim Submitter Trace Number

277

TRN

Claim Submitter Trace Number

278 Request

HL

Service Level HL

278 Response

HL

Service Level HL

820

Not Applicable

834

INS

Member Level Detail

835

Not Applicable

837D

CLM

Claim Information

837I

CLM

Claim Information

837P

CLM

Claim Information

Merging transactions

Individual files comprising single business documents that result from HIPAA Transaction Manager's split command, are then reprocessed by the HIPAA compliance maps. Those that pass are then optionally merged into new transactions that are then sent back to the primary flow (as shown in Figure 2-1) as though they had never contained errors.

Input to the merge command can comprise one or many files. Similarly, output can be one or more files, where each output file contains one and only one interchange containing one and only one business document, such as a claim. Each merged file contains only one interchange. Multiple interchanges rebundle into multiple files.

For transactions that contain hierarchical (HL) segments, the values in the HL01, HL02 and HL04 data elements are resequenced in both the split and merge commands. The SBR (subscriber) segment is also manipulated for 837 transactions.


Chapter 2: Running HIPAA Transaction Manager [Table of Contents] Configuring HIPAA Transaction Manager