EDI HIPAA compliance

EdiFabric has helped customers to acquire CAQH Certifications and our products are used to boost claims, remittance, eligibility and claims status processing by several major HIPAA clearing houses.

The seven HIPAA SNIP levels (types) are:

  • Type 1 EDI Standard Integrity Testing: Validate basic syntactical integrity of the EDI submission.
  • Type 2 HIPAA Implementation Guide Requirement Testing: Validate HIPAA requirement-guide-specific syntax requirement by checking limits on repeat counts, used or not used qualifiers, code, elements, and segments.
  • Type 3 HIPAA Balance Testing: Validate that claim line items amounts are equal to total claim amount.
  • Type 4 HIPAA Inter-Segment Situation Testing: Validate inter-segment relationship. For example, if element A exists, then element B must be populated.
  • Type 5 HIPAA External Code Set Testing: Validate specific code set values for HIPAA standards.
  • Type 6 Product Type/Type of Service Testing: Validate that segments that differ based on certain Health-care services are properly created and processed.
  • Type 7 Trading Partner-Specific Testing: Compliance with payer specific requirement. However, this is not implemented in the Oracle Health-care/B2B set up.

EdiFabric supports all HIPAA validation level types out of the box. Any extra partner specific, custom code or product type requirements can be achieved by either amending the EDI rule class or extending the validation logic.

The following attributes are used to enable conditional validation and can be applied to any data element property:

Conditional Attribute - if the annotated element is not null then all elements at the specified positions must also be not null.

[Conditional(5)]
[StringLength(1, 18)]
[DataElement("782", typeof(X12_R))]
[Pos(6)]
public string AdjustmentAmount_06 { get; set; }

ConditionalAny Attribute - if the annotated element is not null then at least one of the elements at the specified positions must also be not null.

[ConditionalAny(6, 7)]
[StringLength(1, 5)]
[DataElement("1034", typeof(X12_ID))]
[Pos(5)]
public string AdjustmentReasonCode_05 { get; set; }

Exclusion Attribute - only one of the elements at the specified positions and the annotated element altogether, must be not null.

[Exclusion(7)]
[StringLength(2, 2)]
[DataElement("156", typeof(X12_ID))]
[Pos(2)]
public string AmbulanceDropoffStateorProvinceCode_02 { get; set; }

Paired Attribute - if any of the elements at the specified positions or the annotated element is not null, then all the elements at the specified positions and the annotated element must be not null.

[Paired(9)]
[DataElement("66", typeof(X12_ID_66_3))]
[Pos(8)]
public string IdentificationCodeQualifier_08 { get; set; }

RequiredAny Attribute - at least one of the elements at the specified positions or the annotated element must be not null.

[RequiredAny(3)]
[StringLength(1, 50)]
[DataElement("127", typeof(X12_AN))]
[Pos(2)]
public string ReferringProviderSecondaryIdentifier_02 { get; set; }