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Standards and Guidelines Reference Manual Contents i
Contents
Introduction 1
Overview .......................................................................................................................... 1 Basic Concepts ................................................................................................................ 1 XML and Flat-File Guidelines .......................................................................................... 2
Guideline Management with TIBCO Foresight Products ................................................. 2
Guideline Merging with GuideMerge ............................................................................... 4
Standards Overview 5
Overview .......................................................................................................................... 5
Supported Standards 7
Overview .......................................................................................................................... 7
Pre-X12 Standards .......................................................................................................... 8 X12 Standards ................................................................................................................. 8
X12 Derivatives .............................................................................................................. 10 Medical Standards ......................................................................................................... 10 EDIFACT Standards ...................................................................................................... 11
EDIFACT Derivatives ..................................................................................................... 13
Other Standards............................................................................................................. 13 XML Standards .............................................................................................................. 13 Flat-File Standards ........................................................................................................ 13
Guideline Overview 15
Overview ........................................................................................................................ 15
Life Cycle of a Guideline ................................................................................................ 16
Anatomy of a Guideline 21
Overview ........................................................................................................................ 21 Explanation for Segment Table Example ...................................................................... 24
Explanation for Segment Detail Page Example ............................................................. 27
Supported Guidelines 29
Overview ........................................................................................................................ 29 HIPAA Guidelines .......................................................................................................... 32 Healthcare Guidelines Non-HIPAA Mandated ............................................................... 38 Healthcare Guidelines for TIBCO Foresight® Community Manager® .......................... 41 General Guidelines ........................................................................................................ 42
Standards and Guidelines Reference Manual Contents ii
Appendix A: HL7 Standards 43
Overview ........................................................................................................................ 43 HL7 in TIBCO Foresight Products ................................................................................. 43 Sample Data and Instream Scripts ................................................................................ 44 Big Picture ...................................................................................................................... 45
HL7 Specific Information ................................................................................................ 46 HL7 Data Types ............................................................................................................. 49
Appendix B: NCPDP Standards 51
Overview ........................................................................................................................ 51 NCPDP in TIBCO Foresight Products ........................................................................... 51
Sample Data and Instream Scripts ................................................................................ 52
Terminology ................................................................................................................... 52
Big Picture ...................................................................................................................... 53 Codes ............................................................................................................................. 54 Elements ........................................................................................................................ 54 Segments ....................................................................................................................... 57
Example Batch ............................................................................................................... 58 Data with no 1.1 “Enveloping” ........................................................................................ 60
Standards and Guidelines Reference Manual Introduction 1
Introduction
Overview
This document is intended as a reference for those who use EDI industry standards
and guidelines or develop customized guidelines using TIBCO Foresight® products.
Basic Concepts
Standards
Standards ensure that electronic data conforms to formatting rules for sending
business documents between companies using delimited, variable-length fields.
Some well-known standards are X12, EDIFACT, and NCPDP.
Industry Guidelines
Industry guidelines further define rules for specific industries.
Examples of types of industry guidelines are those related to healthcare, pharmacies,
and transportation logistics.
Standards and Guidelines Reference Manual Introduction 2
Customized Guidelines
Customized guidelines are those you develop using a published standard or guideline
as a starting point. They further define rules in places where the standard or industry
guideline is not specific enough or you need specialized behavior. Customized
guidelines are also referred to as companion guidelines.
Production Guidelines
Production guidelines are guidelines for TIBCO Foresight® Instream® and TIBCO
Foresight® HIPAA Validator Desktop® that you create by merging a user guideline
with a TIBCO Foresight guideline.
XML and Flat-File Guidelines
Unlike EDI, XML and flat-file guidelines are not firmly based on standards.
Therefore, you will notice differences in how they are implemented in TIBCO
Foresight products. For more information refer to the following documents:
Using XML (XMLatForesight.pdf)
Using Flat Files (FlatFilesAtForesight.pdf)
Guideline Management with TIBCO Foresight Products
All TIBCO Foresight products
Read guidelines from their databases (.STD files)
List guidelines so that you can select one.
Foresight products also have specific roles when working with guidelines:
Foresight Product Role of Product Role of Guideline
TIBCO Foresight® EDISIM®
Allows you to build, publish, and test companion guidelines for use during EDI transaction processing and validation.
Create company guidelines
Uses guidelines to print documentation, make test data, validate types 1, 2, and 8, migrate guidelines to new version, view parts of guideline
Standards and Guidelines Reference Manual Introduction 3
Foresight Product Role of Product Role of Guideline
HIPAA Validator Desktop®
Validates data according to industry standards, custom guidelines, and specific business rules.
Provides the ability to correct data.
Uses guidelines to validate data types 1-8 (one file at a time)
Instream® Validates data according to industry standards, custom guidelines, and specific business rules.
Use guidelines to validate data types 1-8 (production)
TIBCO Foresight® Transaction Insight®
Enterprise-wide, partner-specific, and detailed transaction reporting and alerts
Advanced search and transaction matching capabilities
Ability to view, share, and correct transactions.
Uses guidelines to collect statistics, view, and correct EDI errors.
TIBCO Foresight® Community Manager®
Ability to check data against guidelines supplied by the Community Manager administrator.
Ability to view and download analysis results.
Uses guidelines to allow partners to validate their own EDI – types 1-8.
Standards and Guidelines Reference Manual Introduction 4
Guideline Merging with GuideMerge
Production guidelines are guidelines for Instream and HIPAA Validator Desktop
that you create by merging a user guideline with a TIBCO Foresight guideline.
HIPAA-based Production guidelines contain type 1-7 edits.
GuideMerge installs with HIPAA Validator® Desktop, EDISIM®, and Windows
versions of Instream.
Guideline Merge lets you merge the changes that you have made to your
guideline in EDISIM Standards Editor with:
TIBCO Foresight-supplied guidelines containing other HIPAA rules
Another EDI or flat file guideline with the same structure.
This lets you have a “master” guideline and then separate guidelines with
additional rules for specific partners, for example.
The parties in a merge are:
Master Spoke Production + =
The guideline that
determines the structure of
the result. All objects
(segments, loops,
elements, etc.) in this
guideline will go into the
production guideline.
The guideline used to
tweak the master
guideline. It should
have the same basic
structure as the
master.
The new guideline
created by the
merge.
Standards and Guidelines Reference Manual Standards Overview 5
Standards Overview
Overview
Standards ensure that electronic data conforms to formatting rules for sending
business documents between companies using delimited, variable-length fields.
Standards can contain many different transaction types. For example X12 standards
provide rules for hundreds of different transactions, often known by their numbers,
like these common ones:
810 Invoice
850 Purchase Order
856 Shipping Notice
997 Functional Acknowledgement
999 Acceptance/Rejection Advice
Supported Standards on page 7 provides a detailed list of the standards and
guidelines that TIBCO Foresight products support at some level.
Standards and Guidelines Reference Manual Supported Standards 7
Supported Standards
Overview
This section provides a listing of the standards:
Supported by EDISIM, Instream, and HIPAA Validator Desktop. (A note
may indicate partial support.)
Shipped with EDISIM, Instream, and HIPAA Validator Desktop.
Additionally, these TIBCO Foresight products support general XML schema and
flat-file definitions, although they do not currently ship with organization schemas
(e.g., MISMO). Please see XML Standards on page 13 and Flat-File Standards on
page 13 for more information.
Standards and Guidelines Reference Manual Supported Standards 8
Pre-X12 Standards
Version Shipped with
EDISIM?
Shipped with
Instream/HIPAA Validator
Desktop?
AIR-24, 25, 26, 27 Yes No
FREIG-26, 27 Yes No
MOTOR-23, 24, 25, 26, 27, 28 Yes No
OCEAN-24, 25, 26, 27, 29 Yes No
RAIL-23, 24, 25, 26, 27, 28 Yes No
TARIF-27 Yes No
UCS-23, 24, 25, 26, 30, 31, 32, 33 Yes No
X12 Standards
Version Shipped with
EDISIM?
Shipped with
Instream/HIPAA Validator
Desktop?
2000 Yes No
2001 Yes No
2002 Yes No
2003 Yes No
2040 Yes No
3010 Yes No
3020 Yes No
3030, 3031, 3032 Yes No
3040, 3041, 3042 Yes No
3050, 3051, 3052 Yes No
3060, 3061, 3062 Yes No
3070, 3071, 3072 Yes No
4010, 4011, 4012 Yes 4010 only
4020, 4021, 4022 Yes No
4030, 4031, 4032 Yes No
4040, 4041, 4042 Yes No
Standards and Guidelines Reference Manual Supported Standards 9
Version Shipped with
EDISIM?
Shipped with
Instream/HIPAA Validator
Desktop?
4050, 4051, 4052 Yes 4050 only
4060, 4061, 4062 Yes No
5010, 5011, 5012 Yes 5010 only
5020, 5021, 5022 Yes No
5030, 5031, 5032 Yes No
5040, 5041, 5042 Yes 5040 only (Instream only)
5050, 5051, 5052 Yes 5050 only
6010, 6011, 6012 Yes Yes
6020, 6021, 6022 Yes Yes
6030, 6031, 6032 Yes Yes
6040, 6041, 6042 Yes Yes
6050, 6051, 6052 Yes Yes
7010, 7011, 7012 Yes No
7020, 7021, 7022 Yes No
7030, 7031, 7032, Yes No
7040, 7041, 7042 Yes No
7050, 7051, 7052 Yes No
7060 Yes No
Standards and Guidelines Reference Manual Supported Standards 10
X12 Derivatives
Version Shipped with
EDISIM?
Shipped with
Instream/HIPAA Validator
Desktop?
HIPAA Original, Addenda (Level 1, 2) Yes Yes
HIPAA Levels 3-7 No
(see note 1)
Yes
UCS: 3030, 3040, 3050, 3060, 3070, 4010,
4020, 4030, 4040, 4050, 5010
Yes No
VICS: 2003, 3010, 3020, 3030, 3040, 3050,
3060, 3070, 4010, 4020, 4030, 4040, 4050,
5010
Yes No
Note 1
The HIPAA Level 3 through 7 guidelines are encrypted within Instream and HIPAA Validator Desktop.
EDISIM will allow the creation of guidelines with additional rules that can be merged with these encrypted
guidelines, but EDISIM does not allow the encrypted HIPAA guidelines to be viewed, printed, or edited.
Medical Standards
Version Shipped with
EDISIM?
Shipped with
Instream/HIPAA Validator
Desktop?
Healthcare Distribution Management
Association (HDMA) 856 Advance Ship
Notice (HDMA-4010856.std)
* Editor, Validator
only
Yes
HL7 2.3, 2.3.1, 2.4, 2.5.1, 2.6 Editor, Reference,
Validator only.
Yes
Medicaid pharmacy subrogation, NCPDP
Telecom D.0/Batch 1.2
* Editor, Validator
only
Yes
NCPDP Telecom 5.1/Batch 1.1 * Editor, Validator
only
Yes
NCPDP Telecom D.0/Batch 1.2 * Editor, Validator
only
Yes
NCPDP Post-Adjudication 4.2**
(NCPDP_PAH42.sef and
NCPDP_PAU42.sef)
* Editor, Validator
only
Yes
Standards and Guidelines Reference Manual Supported Standards 11
Version Shipped with
EDISIM?
Shipped with
Instream/HIPAA Validator
Desktop?
NSF 3.1 * Editor, Validator
only
Yes
UB-92 6.0 * Editor, Validator
only
Yes
* does not ship with EDISIM. Contact TIBCO Foresight support.
** To use this guideline a minimum of Instream 8.4.0 Hotfix 4 and EDISIM 6.14.0 Hotfix 3 are required.
EDIFACT Standards
Version Shipped with
EDISIM?
Shipped with
Instream/HIPAA Validator
Desktop?
UN1ICS Yes Instream only
UN4ICS Yes No
UN40ICS Yes Instream only
UN41ICS Yes Instream only
UN-901, 901v4, 902, 902v4 Yes No
UN-911, 911v4, 912, 912v4 Yes No
UN-921, 921v4 Yes No
UNCTRL Yes No
D93A, D93Av4 Yes D93A only (Instream only)
S93A, S93Av4 Yes No
D94A, D94Av4, D94B, D94Bv4 Yes No
D95A, D95Av4, D95B, D95Bv4 Yes No
D96A, D96Av4, D96B, D96Bv4 Yes D96A only (Instream only)
D97A, D97Av4, D97B, D97Bv4 Yes No
D98A, D98Av4, D98B, D98Bv4 Yes No
D99A, D99Av4, D99B, D99Bv4 Yes No
D00A, D00Av4, D00B, D00Bv4 Yes No
D01A, D01Av4, D01B, D01Bv4, D01C,
D01Cv4
Yes No
D02A, D02Av4, D02B, D02Bv4 Yes No
Standards and Guidelines Reference Manual Supported Standards 12
Version Shipped with
EDISIM?
Shipped with
Instream/HIPAA Validator
Desktop?
D03A, D03Av4, D03B, D03Bv4 Yes No
D04A, D04Av4, D04B, D04Bv4 Yes No
D05A, D05Av4, D05B, D05Bv4 Yes No
D06A, D06Av4, D06B, D06Bv4 Yes No
D07A, D07Av4, D07B, D07Bv4 Yes No
D08A, D08Av4, D08B, D08Bv4 Yes No
D09A, D09Av4, D09B, D09Bv4 Yes No
D10A, D10Av4, D10B, D10Bv4 Yes No
D11A, D11AV4 D11B*, D11BV4* Yes No
D12A*, D12AV4*, D12B*, D12BV4* Yes No
D13A*, D13AV4, D13B*, D13BV4* Yes No
D14A, D14AV4*, D14B*, D14BV4* Yes No
D15AC, D15AV4*, D15B*, D15BV4* Yes No
D16A*, D16AV4*, D16B*, D16BV4* Yes No
D17A*, D17AV4* D17B*, D17BV4* Yes No
D18A*, D18AV4, D18B*, and D18BV4* Yes No
D19A*, D19AV4* Yes No
* These standards contain 5-digit sequence numbers. Install EDISIM 6.18.0 or later before using these standards.
Standards and Guidelines Reference Manual Supported Standards 13
EDIFACT Derivatives
Version Shipped with
EDISIM?
Shipped with Instream/HIPAA
Validator Desktop?
EANCOM93 Yes No
EAN97 (Version 3 and 4) Yes No
EAN02 (Syntax 3 and 4) Yes No
Other Standards
Version Shipped with
EDISIM?
Shipped with Instream/HIPAA
Validator Desktop?
ACH (ACH_CCDp and ACD_CTX) All except TDG,
Comparator, and
Analyzer
No
GENCOD 5 All except TDG No
ODETTE 94 All except TDG No
TRADACOMS Version 9 – 93 All except TDG Yes
XML Standards
EDISIM Standards Editor lets you import and customize XML schemas and DTDs.
It can then be saved as a standard and used in EDISIM Validator and
Instream/HIPAA Validator Desktop to validate XML data and to create HTML
reports of validation results. EDISIM TDG does not support XML schemas.
Flat-File Standards
EDISIM Standards Editor lets you create both fixed-length and delimited flat file
‘guidelines’, along with custom enveloping. You can use these flat-file guidelines in
EDISIM Validator and Instream/HIPAA Validator Desktop to validate flat-file
data, and to create HTML reports of validation results. EDISIM TDG and
Comparator do not support flat-file guidelines.
Standards and Guidelines Reference Manual Guideline Overview 15
Guideline Overview
Overview
Industry Guidelines
Industry guidelines (also referred to as Published guidelines) further define rules for
specific industries. For example, HIPAA guidelines have been developed based on
X12 standards related to healthcare.
Examples of other types of industry guidelines are those related to pharmacies and
transportation.
Customized Guidelines
Customized guidelines are those you develop using a published standard or guideline
as a starting point. They further define rules in places where the standard or industry
guideline is not specific enough or you need specialized behavior to use the
guideline with other Foresight products such as Dataswapper or Transaction
Insight®.
For example, you may want to mark certain optional fields as “not used, add internal
notes, etc. Customized guidelines are also referred to as companion guidelines.
Standard HIPAA Guidelines Developed
Health Care Claim Status Response (277-X212)
Health Care Claim Status Response Unsolicited (277U-X212)
Health Care Claim Acknowledgement (277CA-X214)
277 Healthcare
Information
Status
Notification
Standards and Guidelines Reference Manual Guideline Overview 16
Life Cycle of a Guideline
Creating a Customized Guideline
Customized guidelines start life in EDISIM Standards Editor. Taking a published
guideline, you can modify the usage, codes, values, and other characteristics to
define exactly how the data should be. TIB_fsp_edisim_<n.n>_fseditor.pdf and
BusinessRules.pdf explain how to do this.
In this document, we base our customized guideline Our837P on 837-X222, a
Foresight-supplied 5010 837P with HIPAA types 1 and 2 rules already built in. How
did we know which guideline to use as a base? We looked it up in Supported
Guidelines on page 29.
We make changes to codes, values, usage, notes, etc., based on instructions in
TIB_fsp_edisim_<n.n>_fseditor.pdf. After saving, Our837P will have types 1, 2,
and 8 (our specifications are considered type 8).
Using a Customized Guideline with EDISIM
Once defined in Standards Editor, the guideline is actually a .STD file in EDISIM’s
User Files\Public Guidelines directory:
From there, it is available to all other EDISIM modules:
Comparator, when in migration mode, can also modify the guideline or create a new
one.
Export to SEF OUR837P
EDISIM Doc
Builder
Test Data
Generator
Analyzer Foresight
Validators
Standards
Reference
Comparator
Standards and Guidelines Reference Manual Guideline Overview 17
Using a Merged Guideline
Merging Guidelines
Since EDISIM can only handle HIPAA types 1, 2, and 8, we have to merge in types
3-7. These are in special HIPAA guidelines that ship with HIPAA Validator
Desktop, Instream, Transaction Insight, Community Manager®, and other HIPAA-
specific products.
We use GuideMerge for this.
GuideMerge ships in the Bin directory of EDISIM and Instream®.
We will merge Our837P with the corresponding types 1-7 guideline, which we look
up in Supported Guidelines on page 29. This gives us a guideline with all HIPAA
rules plus our own rules from Our837P. We call it P_Our837P:
Our837P + PDSA5010837P = P_Our837P
This follows the custom of putting a P in front of the EDISIM guideline to identify
it as the “production” guideline - the one to be used with the HIPAA products.
GuideMerge.pdf gives all the details. Let’s assume that we are doing the merge
from a machine that is running Instream. Here’s what we would do:
1. Copy Our837P from EDISIM’s User Files\Public Guideline directory to
somewhere on the Instream machine.
2. Run GuideMerge to create P_Our837P.std.
Using Merged Guidelines with Instream
Copy the resulting P_Our837P to Instream’s Database directory.
If you have made other changes associated with the guideline, such as changes to the
validation profile (APF), the customer error message file, external tables or
databases, the $dir.ini, etc., include these in Instream too.
We now have guidelines and associated files in these places:
Standards and Guidelines Reference Manual Guideline Overview 18
Using Merged Guidelines with TIBCO Foresight® Translator.
Copy the resulting P_Our837P to Foresight® Translator’s Database directory.
Foresight Translator does not need the APF, customer errors file, etc.
Using Merged Guidelines with Transaction Insight®
The web portal machine must have an installation of Instream with the same
guidelines and related files that were used for validation.
After initial validation, the detail results file is imported into Transaction Insight. A
Transaction Insight user corrects the data and it is sent to Instream to revalidate.
Typically, the two instances of Instream are not on the same server.
P_Our837P.std
(Types 1-8)
EDISIM Machine Instream
Our837P.std
(Types 1, 2, 8)
APF
CustomerFSBRErrs.txt
tables
databases
APF
CustomerFSBRErrs.txt
tables
databases
Instream
Validation
(P_Our837P,
APF, errors file,
etc.)
DTL file EDI
Transaction
Insight
Instream
Revalidation
(P_Our837P,
APF, errors file,
etc.)
P_Our837P.std
(Types 1-8)
Our837P.std
(Types 1, 2, 8)
APF
CustomerFSBRErrs.txt
tables
databases
EDISIM
EDISIM Foresight Translator
Standards and Guidelines Reference Manual Guideline Overview 19
A more complete overview of a typical process like this might be:
DTL file EDI Instream
validation Response
Generator
999,
etc.
Docsplitter
Good Translator
Bad Transaction
Insight
Standards and Guidelines Reference Manual Anatomy of a Guideline 21
Anatomy of a Guideline
Overview
The following pages show an annotated example guideline document. Unused
segments were not printed in this example.
Standards and Guidelines Reference Manual Anatomy of a Guideline 23
See next page for explanations ->
Standards and Guidelines Reference Manual Anatomy of a Guideline 24
Explanation for Segment Table Example
Page header. By default, there is no page header. You can insert one in EDISIM Doc Builder
under Profile | Options | Formatting tab.
Transaction or message title. You can change this in Standards Editor. Click on the
Transaction or message line at the top and change the Description in the top pane or in the
bottom pane’s Detail tab.
Functional group (X12 only). Normally, this should not be changed. If necessary, you can
change it in Standards Editor. Click on the transaction or message at the top, and then change
the Functional Group field in the bottom pane’s Detail tab.
Transaction or message purpose. You can change it in Standards Editor. Click on the
transaction or message at the top, and then change the Purpose field in the bottom pane’s
Detail tab.
Level notes. The top one is a level 1 note. The next one is a level 2 note. In this example, the
names of the note levels have been changed in Standards Editor. Use File | Properties | Level
Notes tab. Slowly click on the Note Name in the bottom of the dialog box and type the name.
To insert or change notes on the first page of the guideline document, click on the transaction
or message, click Edit Notes in the bottom pane’s Detail tab, select the level, and then type the
note.
Segment position number, showing position of the segment within the transaction or
message. You can change this position number in Standards Editor. Click on the transaction or
message at the top, and then change the Position Number field in the bottom pane’s Detail tab.
Be sure the new number is between the numbers of the surrounding segments, whether they are
used or not used.
Segment ID or tag. You cannot change it directly. Instead, use Standards Editor to create a
new segment in the segment dictionary and then insert it in this position in the transaction or
message.
Segment name or description. You can change this in EDISIM Standards Editor. To change
it in a particular location, click on the segment in the transaction set or message, and then
change the Description field in the bottom pane’s Detail tab. To change it throughout the
guideline, click on Dictionary Segments, to the same in the Segment dictionary under Dictionary
Objects at the top.
Segment requirement designator or status. This shows the requirement according to the
published standard on which your guideline is based. Normally, this should not be changed. If
necessary, you can change it in EDISIM Standards Editor. Click on the segment in the top
pane, and then change the Requirement Designator field in the bottom pane’s Detail tab.
B
C
D
E
F
G
H
I
A
Standards and Guidelines Reference Manual Anatomy of a Guideline 25
Segment maximum use. You can change this in EDISIM Standards Editor. Click on the
segment in the top pane, and then change the Repeat Count field in the bottom pane’s Detail
tab.
Loop/group repeat count. You can change this in EDISIM Standards Editor. Click on the
Loop header in the top pane, and then change the Repeat Count field in the bottom pane’s
Detail tab.
Transaction or message notes and comments from the original standard. You cannot see or
change them in EDISIM Standards Editor. If you need to change them, use EDISIM Doc
Builder to export your guideline into a RTF file and open it in a word processor.
Notes start with “n” and are explained in the Transaction Set Notes section that appears after
the summary table.
Comments start with “c” and are explained in the Transaction Set Comments section that
appears after the summary table.
User requirement according to your own guideline. You can change this in EDISIM Standards
Editor. Click on the segment in the top pane, and then change the User Attributes field in the
bottom pane’s Detail tab.
Default footer. It includes the guideline’s name. It also includes the parent standard, page
number, and date that the document was generated in EDISIM Doc Builder. You can change
these in Document Builder. Open the guideline and choose Profile | Options | Formatting
tab.
K
L
M
N
J
Standards and Guidelines Reference Manual Anatomy of a Guideline 26
Sample Segment Detail Page
O
P
Q
R
S T U
R
V
W X
See next page for explanations ->
Standards and Guidelines Reference Manual Anatomy of a Guideline 27
Explanation for Segment Detail Page Example
Level (Heading, Detail, etc.) in which the segment appears.
Segment purpose. You can change this in EDISIM Standards Editor. Click on the segment in
the top pane, and then change the Purpose field in the bottom pane’s Detail tab. To change it
throughout the transaction, make the change in the Segments dictionary.
Syntax Notes, Semantic Notes, and Comments. You can change this in EDISIM Standards
Editor. Click on the segment in the segment dictionary and then make the changes in the
bottom pane’s Detail tab.
Level 1, 2, and 3 notes on segments, elements, or code values. You can change this in
EDISIM Standards Editor. Click on the segment or element and choose Edit Notes in the
bottom pane’s Detail tab. For a code, double-click on the code.
User requirement. Requirement according to your guideline. EDISIM Doc Builder options
(Profile | Options | Text Options) let you change how this appears (>>, "Must Use,"
"M/U," etc.). You can change the attribute in EDISIM Standards Editor. Click on the segment
or element in the top pane, and then change the User Attributes field in the bottom pane’s
Detail tab.
Element Name or Description. You can change this in EDISIM Standards Editor. Click on the
element and use the Description field in the bottom pane’s Detail tab. You can also change it in
the segment, composite, or element dictionaries if you want the change to be throughout the
guideline.
Attributes or representation. You can change this in EDISIM Standards Editor. Click on the
element and use the bottom pane’s Detail tab. The information includes:
Requirement. If you have selected Single Attribute Column under EDISIM Doc Builder’s
Profile Element Items tab, this is the effective requirement. Otherwise, it is the requirement
according to the underlying standard. You can change the effective requirement by
changing the user attributes in EDISIM Standards Editor. Click on the element and use the
Requirement Designator field in the bottom pane.
Repeat count. Change in EDISIM Standards Editor. Click on the element and use the
Repeat Count field in the bottom pane’s Detail tab.
Data type. Change in EDISIM Standards Editor. Click on the element in the Element
dictionary and use the Type field in the bottom pane’s Detail tab. See also DataTypes.pdf
in EDISIM’s Documentation directory. This is a global change.
Minimum length and maximum length. Change in EDISIM Standards Editor. Click on
the element and use the Minimum and Maximum fields in the bottom pane’s Detail tab.
P
R
S
T
U
O
Q
Standards and Guidelines Reference Manual Anatomy of a Guideline 28
Element Purpose. You can change in EDISIM Standards Editor. Click on the element and use
the Purpose field in the bottom pane’s Detail tab.
Code value. BT is the only code value that is valid here, according to this guideline. Code
values only appear here if you have changed the original list from the originating standard. You
can change this list in EDISIM Standards Editor. Click on the element in the top pane and use
the Code Values tab at the bottom. You can also work with codes in the element, composite, or
segment dictionary. To change a code’s description, purpose, minimum, maximum, or type, use
the Element dictionary.
Code value definition and explanation (if any). You can change this list in EDISIM
Standards Editor. Click on the element in the top pane and use the Code Values tab at the
bottom. You can also work with codes in the element, composite, or segment dictionary.
V
W
X
Standards and Guidelines Reference Manual Supported Guidelines 29
Supported Guidelines
Important Information about Standard and Healthcare Guidelines for TIBCO Foresight® Instream® Users
Instream is available in two versions: Instream Standard Edition and Instream
Healthcare Edition.
Healthcare-related guidelines are shipped with both Instream Standard Edition and
Instream Healthcare Edition; however the following usage restrictions apply:
For customers who have licensed Instream Healthcare Edition, you may use the
healthcare guidelines included in Instream Healthcare Edition.
For customers who have licensed Instream Standard Edition, you may not use
any of the healthcare guidelines included in Instream Healthcare Edition.
Overview
TIBCO Foresight guidelines
Guidelines that ship with EDISIM, Instream, and HIPAA
Validator Desktop.
HIPAA
For those using TIBCO Foresight HIPAA validation products,
these guidelines in EDISIM contain types 1 and 2 edits.
HIPAA-based TIBCO Foresight guidelines in Validator
include these same EDISIM guidelines plus additional
guidelines with types 1-6 edits.
User guidelines Guidelines that you create in EDISIM Standards Editor. They
contain your company's edits.
Standards and Guidelines Reference Manual Supported Guidelines 30
Production guidelines Guidelines for Instream and HIPAA Validator Desktop that
you create by merging a user guideline with a TIBCO Foresight
guideline. HIPAA-based Production guidelines contain type 1-
7 edits.
Standards and Guidelines Reference Manual Supported Guidelines 32
HIPAA Guidelines
This document lists guidelines provided with the following TIBCO Foresight products: EDISIM, HIPAA Validator Desktop, and TIBCO
Foresight Instream. They include X12-4010, X12-4050, X12-5010 Errata, Public Companion Guides, and other Healthcare related guidelines.
Notes
1. X12-4010 —supported, however changes are no longer being incorporated into these guidelines.
2. X12-5010 before June 2010 Errata —supported, however these guidelines are no longer shipped with TIBCO Foresight products.
Standards and Guidelines Reference Manual Supported Guidelines 33
Table 1 - X12-4010
Version X12-4010
Document Name
EDISIM
Non-Addenda
Types 1-2
EDISIM
Addenda
No SVALU
Records
Types 1-2
HIPAA
Validator
Desktop or
Instream
Non-Addenda
Types 1-7
HIPAA Validator
Desktop or
Instream
Addenda
No SVALU Recs
Types 1-7
GuidelinePlus
Instream only
Addenda
SVALU Recs
Types 1-7 (PDSA)/
Types 1-2 (PDSX)
(www.wpc-
edi.com)
Value in GS08
(A1 at end =
Addenda)
Notes
270 Eligibility, Coverage or
Benefit Inquiry
270-A120 270AA120 4010270 B41A270
PDSA270
PDSX270
X092.pdf 004010X092
004010X092A1
271 Eligibility, Coverage or
Benefit Information
271-A120 271AA120 4010271 B41A271
PDSA271
PDSX271
X092.pdf 004010X092
004010X092A1
276 Health Care Claim Status
Request
276-A120 276AA120 4010276
B41A276 PDSA276
PDSX276
X093.pdf 004010X093
004010X093A1
277 Health Care Claim Status
Notification
277-A120 277AA120 4010277 B41A277
PDSA277
PDSX277
X093.pdf 004010X093
004010X093A1
277 Health Care Claim Status
Notification - unsolicited
277U-AA120 n/a
PDSX277U
004010
004010X093
004010X093A1
278 Health Care Services
Review Information –
Request for Review
278-A120 278AREQ 41-278RQ 41A278RQ
PDA278RQ
PDX278RQ
X094.pdf 004010X094
004010X094A1
BHT02=13
278 Health Care Services
Review Information –
Response to Request for
Review
278-A320 278ARES 41-278RP 41A278RP
PDA278RP
PDX278RP
X094.pdf 004010X094
004010X094A1
BHT02=11
820 Payment Order /
Remittance Advice
820-A120 820AA120 4010-820 B41A820
PDSA820
PDSX820
X061.pdf 004010X061
004010X061A1
Standards and Guidelines Reference Manual Supported Guidelines 34
Version X12-4010
Document Name
EDISIM
Non-Addenda
Types 1-2
EDISIM
Addenda
No SVALU
Records
Types 1-2
HIPAA
Validator
Desktop or
Instream
Non-Addenda
Types 1-7
HIPAA Validator
Desktop or
Instream
Addenda
No SVALU Recs
Types 1-7
GuidelinePlus
Instream only
Addenda
SVALU Recs
Types 1-7 (PDSA)/
Types 1-2 (PDSX)
(www.wpc-
edi.com)
Value in GS08
(A1 at end =
Addenda)
Notes
834 Benefit Enrollment and
Maintenance
834-A120 834AA120 4010834 B41A834
PDSA834
PDSX834
X095.pdf 004010X095
004010X095A1
835 Health Care Claim
Payment/Advice
835-W120 835AW120 4010-835 B41A835
PDSA835
PDSX835
X091.pdf 004010X091
004010X091A1
837 Health Care Claim:
Professional
837-Q120 837AQ120 4010837P B41A837P (*CCI) PDSA837P (*CCI)
PDSX837P
X098.pdf 004010X098
004010X098A1
Uses SV1
segment
837 Health Care Claim: Dental 837-Q220 837AQ220 4010837D B41A837D
PDSA837D
PDSX837D
X097.pdf 004010X097
004010X097A1
Uses SV3
segment
837 Health Care Claim:
Institutional
837-Q320 837AQ320 4010837I B41A837I
PDSA837I
PDSX837I
X096.pdf 004010X096
004010X096A1
Uses SV2
segment
997 Functional
Acknowledgement
n/a n/a n/a n/a PDSA997
4010-997
Generic X12-4010 997 (no HIPAA rules),
although PDSA997 does generate structure
records in Instream DTL file.
Standards and Guidelines Reference Manual Supported Guidelines 35
Table 2 - X12-4050
Version X12-4050
Document Name
EDISIM Non-Addenda
Types 1-2
HIPAA Validator Desktop or Instream Addenda No SVALU Records
Types 1-7
GuidelinePlus Instream only Addenda SVALU Records
Types 1-7 /
Types 1-2
PDF (www.wpc-edi.com)
Value in GS08
Notes
275 Additional Information
to Support a Health
Care Claim or
Encounter
275-X151 4050-275 n/a 275-X151.pdf 004050X151
277 Health Care Claim
Request for Additional
Information
277-X150 4050-277 n/a 277-X150.pdf 004050X151
Standards and Guidelines Reference Manual Supported Guidelines 36
Table 3 - X12-5010 June 2010 Errata X12-5010 June 2010 Errata
Document Name
EDISIM **
Types 1-2
HIPAA Validator
Desktop or Instream
*
Types 1-2
HIPAA Validator Desktop or Instream
No SVALU Records
Types 1-7
GuidelinePlus
Instream only
DS, RG, TI Types 1-7 Types 1-2
(www.wpc-edi.com)
Value in GS08
Notes
270 Eligibility, Coverage or
Benefit Inquiry
270-X279 270-X279 5010-270X279 PDSA5010270X279
PDSX5010270X279
x203_270_271.pdf 005010X279A1
271 Eligibility, Coverage or
Benefit Information
271-X279 271-X279 5010-271X279 PDSA5010271X279
PDSX5010271X279
x203_270_271.pdf 005010X279A1
276 Health Care Claim
Status Request
276-X212 276-X212 5010-276X212 PDSA5010276X212
PDSX5010276X212
276-X212-5010.pdf 005010X212
276 Health Care Claim
Status Request –
Medicare
n/a 5010-MEDICARE-
276X212
PDSA5010MEDICARE-
276X212
none 005010X212
277 Health Care Claim
Status Response
277-X212 277-X212 5010-277X212 PDSA5010277X212
PDSX5010277X212
277-X212-5010.pdf 005010X212
277 Health Care Claim
Status Response –
Unsolicited
277U-X212 277U-X212 n/a n/a
PDSX5010-277UX212
005010
005010X212
277 Health Care Claim
Acknowledgement
277CA-X214 277CA-X214 5010-277CAX214 PDSA5010277CAX214
PDSX5010277CAX214
X214_277CA.pdf 005010X214
277 Health Care Claim
Status Response-
Medicare
n/a 5010-MEDICARE-
277X212
PDSA5010MEDICARE-
277X212.std
none 005010X212
278 Health Care Services
Request for Review
278X217Q 278X217Q 5010-278X217Q PDSA5010278X217Q
PDSX5010278X217Q
278X217Q-
5010.pdf
005010X217 BHT02=01,
13, or 36
Standards and Guidelines Reference Manual Supported Guidelines 37
X12-5010 June 2010 Errata
Document Name
EDISIM **
Types 1-2
HIPAA Validator
Desktop or Instream
*
Types 1-2
HIPAA Validator Desktop or Instream
No SVALU Records
Types 1-7
GuidelinePlus
Instream only
DS, RG, TI Types 1-7 Types 1-2
(www.wpc-edi.com)
Value in GS08
Notes
278 Health Care Services
Response to Review
278X217R 278X217R 5010-278X217R PDSA5010278X217R
PDSX5010278X217R
278X217R-5010.pdf 005010X217 BHT02=11
820 Payroll Deducted and
Other Group Premium
Payment for
Insurance Products
820-X218 820-X218 5010-820 PDSA5010820
PDSX5010820
820-x218-5010.pdf 005010X218
824 Application Advice 824-X166
824-X186A1
824-X166
824-X186A1
n/a n/a 824-x166-5010.pdf
824-x186A1-
5010.pdf
005010X166
005010X186A1
834 Benefit Enrollment
and Maintenance
834-X220 834-X220 5010-834 PDSA5010834
PDSX5010834
834-x220-5010.pdf
005010X220A1
835 Health Care Claim
Payment/Advice
835-X221 835-X221 5010-835 PDSA5010835
PDSX5010835
835-X221-5010.pdf 005010X221A1
837D Health Care Claims
Dental
837-X224 837-X224 5010837D PDSA5010837D
PDSX5010837D
837-x224-5010.pdf 005010X224A2
Uses SV1
segment
837I Health Care Claim
Institutional
837-X223 837-X223 5010837I PDSA5010837I
PDSX5010837I
837-x223-5010.pdf 005010X223A2
Uses SV3
segment
837I Health Care Claim
Institutional –
Medicare A
n/a n/a 5010-
MEDICAREA
PDSA5010MEDICAREA none 005010X223A2 Uses SV2
segment
837P Health Care Claim
Professional
837-X222 837-X222 5010837P (*CCI) PDSA5010837P (*CCI)
PDSX5010837P
837-x222-5010.pdf 005010X222A1
Standards and Guidelines Reference Manual Supported Guidelines 38
X12-5010 June 2010 Errata
Document Name
EDISIM **
Types 1-2
HIPAA Validator
Desktop or Instream
*
Types 1-2
HIPAA Validator Desktop or Instream
No SVALU Records
Types 1-7
GuidelinePlus
Instream only
DS, RG, TI Types 1-7 Types 1-2
(www.wpc-edi.com)
Value in GS08
Notes
837P Health Care Claim
Professional –
Medicare B
n/a n/a 5010-
MEDICAREB
(*CCI)
PDSA5010MEDICAREB
(*CCI)
none 005010X222A1
Healthcare Guidelines Non-HIPAA Mandated
Document Name
EDISIM **
Types 1-2
HIPAA Validator
Desktop or Instream
*Types 1-2
HIPAA Validator Desktop or Instream
No SVALU Records
Types 1-7
GuidelinePlus
Instream only
DS, RG, TI Types 1-7 Types 1-2
PDF (www.wpc-edi.com)
Value in GS08
275 Health Care Claim or
Encounter
275-X314 275-X314 6020-275X314 PDSA6020-275X314
PDSX6020-275X314
275-X314-6020.pdf 006020X314
275 Health Care Services
Review
275-X316 275-X316 6020-275X316 PDSA6020-275X316
PDSX6020-275X316
275-X316-6020.pdf 006020X316
277 Health Care Claim
Pending Status
Information
277-X228 277-X228 n/a PDSX5010-277X228
277-X228-5010.pdf 005010X228
277 Health Care Claim
Request for Additional
Information (277)
277-X213 277-X213 n/a PDSX5010-277X213 277-X213-5010.pdf 005010X213
Standards and Guidelines Reference Manual Supported Guidelines 39
Document Name
EDISIM **
Types 1-2
HIPAA Validator
Desktop or Instream
*Types 1-2
HIPAA Validator Desktop or Instream
No SVALU Records
Types 1-7
GuidelinePlus
Instream only
DS, RG, TI Types 1-7 Types 1-2
PDF (www.wpc-edi.com)
Value in GS08
277 Health Care Claim
Request for Additional
Information
277-X313 277-X313 6020-277X313 PDSA6020-277X313
PDSX6020-277X313
277-X313-6020.pdf 006020X313
277 Data Reporting
Acknowledgment
277-X364 277-X364 5010-277DRAX364 PDSA5010277DRAX364 277-X364-5010.pdf 005010X364
278 Health Care Services
Review Information -
Inquiry
278X215I 278X215I 5010-278X215I PDSA5010-278X215I
PDSX5010-278X215I
278-X215I-5010.pdf 005010X215
278 Health Care Services
Review Information -
Response
278X215R 278X215R 5010-278X215R PDSA5010-278X215R
PDSX5010-278X215R
278-X215R-5010.pdf 005010X215
278 Health Care Services
Review Information -
Acknowledgement
278X216A 278X216A 5010-278X216A PDSA5010-278X216A
PDSX5010-278X216A
278-X216A-5010.pdf 005010X216
278 Health Care Services
Review Information -
Notification
278X216N 278X216N 5010-278X216N PDSA5010-278X216N
PDSX5010-278X216N
278-X216N-5010.pdf 005010X216
820 Health Insurance
Exchange: Related
Payment
820-X306 820-X306 5010-820X306 PDSA5010-820X306
PDSX5010-820X306
820-x306-5010.pdf 005010X306
820 Health Insurance
Exchange: Related
Payment (CMS
Companion Guideline)
n/a 820-X306 5010-HIX-820X306 PDSA5010HIX-820X306 No PDF 005010X306
834 Benefit Enrollment And
Maintenance: Health Care
Exchange (CMS
n/a 834-X220 5010-HIX-834X22 PDSA5010HIX-834X220 No PDF
005010X220A1
Standards and Guidelines Reference Manual Supported Guidelines 40
Document Name
EDISIM **
Types 1-2
HIPAA Validator
Desktop or Instream
*Types 1-2
HIPAA Validator Desktop or Instream
No SVALU Records
Types 1-7
GuidelinePlus
Instream only
DS, RG, TI Types 1-7 Types 1-2
PDF (www.wpc-edi.com)
Value in GS08
Companion Guideline)
834 Health Insurance
Exchange: Enrollment
834-X307 834-X307 5010-834X307 PDSA5010-834X307
PDSX5010-834X307
834-x307-5010.pdf 005010X307
834 Plan Member Reporting 834-X318 834-X318 5010-834X318 PDSA5010-834X318
PDSX5010-834X318
834-x318-5010.pdf 005010X318
837D Dental, Post-Adjudication
Claims Data Reporting
837-X300 837-X300 5010-837X300 PDSA5010-837X300
PDSX5010-837X300
837-x300-5010.pdf 005010X300
837I Institutional, Post-
Adjudication Claims Data
Reporting
837-X299 837-X299 5010-837X299 PDSA5010-837X299
PDSX5010-837X299
837-x299-5010.pdf 005010X299
837P Professional, Post-
Adjudication Claims Data
Reporting
837-X298 837-X298 5010-837X298 PDSA5010-837X298
PDSX5010-837X298
837-x298-5010.pdf 005010X298
997 Functional
Acknowledgment
5010-997 5010-997 n/a n/a
PDSX5010997
No PDF
005010
999 Implementation
Acknowledgment
999-X231 999-X231 5010-999X231 PDSA5010-999X231
PDSX5010-999X231
999_X231.pdf 005010
005010X231
Standards and Guidelines Reference Manual Supported Guidelines 41
Healthcare Guidelines for TIBCO Foresight® Community Manager®
Guideline Name Purpose Notes
FSSD5010-270X279
FSSD5010-271X279
FSSD5010-276X212
FSSD5010-277X212
FSSD5010-278X217REQ
FSSD5010-278X217RES
FSSD5010-820X218
FSSD5010-834X220
FSSD5010-835X221
FSSD5010-837DX224
FSSD5010-837IX223
FSSD5010-837PX222
FSSD5010-MEDICAREA
FSSD5010-MEDICAREB
Community Manager® only
For customers who host their own Community Manager, merge these with your
company guidelines to create production guidelines that contain scenarios.
Guidelines are installed in Instream’s
CommunityManagerGuidelines directory.
Standards and Guidelines Reference Manual Supported Guidelines 42
General Guidelines
Document Name Purpose GuidelinePlus
SVALU Records
GS01
210 Motor Carrier Freight Details and Invoice
TIBCO Foresight Transaction Insight
Standard Edition
PDSAGM5010-210 IM
810 Invoice PDSAGM5010-810 IN
820 Payment Order/Remittance Advice PDSAGM5010-820 RA
850 Purchase Order PDSAGM5010-850 PO
855 Purchase Order Acknowledgment PDSAGM5010-855 PR
856 Ship Notice/Manifest PDSAGM5010-856 SH
860 Purchase Order Change Request – Buyer Initiated PDSAGM5010-860 PC
Standards and Guidelines Reference Manual Appendix A: HL7 Standards 43
Appendix A: HL7 Standards
Overview
This section describes how to use HL7 transactions, also known as “messages”, in
TIBCO Foresight products.
Health Level Seven International (HL7) has data interchange standards for health
information transactions. HL7 Version 2 Messaging Standards versions as listed below
are supported by TIBCO Foresight validation products.
HL7 in TIBCO Foresight Products
The HL7 guidelines
2.3
2.3.1
2.4
2.5.1
2.6
are distributed with these TIBCO Foresight products:
HIPAA Validator Desktop version 8.0.0 or later
Instream version 8.0.0 or later – validation only.
You can use them with these modules of EDISIM 6.10.1 or later (copy the appropriate
standard, for example HL7_26.std, from Instream’s or HIPAA Validator Desktop’s
Database folder to EDISIM’s User Files\Public Guidelines directory):
EDISIM Standards Editor – including the ability to create rules
EDISIM Standards Reference
Standards and Guidelines Reference Manual Appendix A: HL7 Standards 44
HL7 does not work with EDISIM’s Doc Builder, Test Data Generator, Comparator,
Analyzer, or Library modules.
HL7 standards and guidelines can also be used with Foresight Translator version 3.0.0 or
later.
Sample Data and Instream Scripts
Instream HIPAA
Validator
Desktop
Filename Directory Notes
HL7_ORU_R01_Clean.txt DemoData HL7 ORU R01 file. Used
by Instream’s
V_ORUR01_HL7_Clean
script.
V_ORUR01_HL7_Clean Scripts Validates
HL7_ORU_R01_Clean.txt,
an HL7 file.
Standards and Guidelines Reference Manual Appendix A: HL7 Standards 45
Big Picture
Messages
HL7 provides the following messages (referred to in the X12 community as transaction
types):
Patient Administration
Order Entry
Queries
Financial Management
Observation Reporting
Master Files
Medical Records/Information Management
Scheduling (View Brief)
Patient Referral
Patient Care
Clinical Laboratory Automation
Application Management
Personnel Management
Claims and Reimbursement
Materials Management
Parts of a Message
HL-7 messages:
Begin with a Start Message (MSH) segment, which contains information such as
from, to, date, time, etc.
Contain no End Message segment. The end of a message is signaled when another
Start Message (or Start Batch or Start File) segment is seen, or upon end-of-file.
One or more messages may be grouped into a Batch, which is explained below.
Start of message
Start of next message
Standards and Guidelines Reference Manual Appendix A: HL7 Standards 46
Parts of a Batch
One or more messages may be grouped into a batch. A batch:
begins with a Start Batch Segment (BHS)
is followed by one or more messages
ends with an End Batch Segment (BTS).
One or more batches may be grouped into a file. A file:
begins with a Start File Segment (FHS)
ends with an End File Segment (FTS).
HL7 Specific Information
Users who are familiar with EDISIM, Instream, HIPAA Validator Desktop, and
Foresight Translator from working with X12 EDI will find the following differences
when working with the HL7 standard.
Terminology
General terminology differences between X12 data and HL7 data are as follows:
X12 HL7
Interchange File
Functional Group Batch
Transaction Set Message
Loop Segment Group
Segment Segment
Sub-Composite Members Field Sub-Components
Element Fields
Code Set Table
Standards and Guidelines Reference Manual Appendix A: HL7 Standards 47
Requirements Coding
The following Requirements characters are used in the Requirements field in HL7
messages:
Character X12 Meaning HL7 Meaning
M Mandatory Required
O Optional Optional
C Conditional Conditional
X (none) Not Used
B (none) Backward
Compatibility
W (none) Withdrawn
Standards and Guidelines Reference Manual Appendix A: HL7 Standards 48
Sub-Composites
Composites in HL7 transactions may contain sub-composites.
Codes
There will be a new Responsible Agency Code of ‘H’ in the fourth field if the .INI
record to identify HL7 standards.
Enveloping
Enveloping differences between X12 data and HL7 data are as follows:
The HL7
segment…
Defined as… Is like this segment in X12…
FSH File Header Segment
(includes delimiter overrides)
ISA (optional)
BSH Batch Header Segment
(includes delimiter overrides)
GS (optional)
MSH Message Header Segment
(includes delimiter overrides)
ST
(none) Message Trailer Segment SE
BST Batch Trailer Segment GE (optional, but required if BSH
is used)
FST File Trailer Segment IEA (optional, but required if FSH
is used)
HL7 Identifier in Validation Detail File
GEN record 17021 within the validation detail file indicates the data is HL7. The “1” in
front of the GEN record number is the line number in the data file.
Composite
Sub-composite
Standards and Guidelines Reference Manual Appendix A: HL7 Standards 49
HL7 Data Types
The following data types are commonly found in HL7 transactions/messages. For
additional information, refer to the official HL7 documentation for Data Types
(http://www.hl7.org).
Data Type Description
AD Address
CCD Charge code and date
CCP Channel calibration parameters
CD Channel definiion
CE Coded ENTRY
CF Coded element with formatted values
CK Composite ID with check digit
CM Composite
CN Composite ID number and name
CNE Coded with no exceptions
CQ Composite quantity with units
CP Composite price
CWE Coded with exceptions
CX Extended Composite ID with check digit
DLN Driver’s license number
DR Date/time range
DT Data
ED Encapsulated data
EI Entity identifier
FC Financial class
FN Family name
FT Formatted text data
HD Hierarchic designator
ID Coded value for HL7-defined tables
IS Coded value for user-defined tables
JCC Job code/class
MA Multiplexed array
Standards and Guidelines Reference Manual Appendix A: HL7 Standards 50
Data Type Description
MO Money
NA Numeric array
NM Numeric
PL Person location
PN Person
PPN Performing person time stamp
SI Sequence ID
PT Processing type
QIP Query input parameter list
QSC Query selection criteria
RCD Row column definition
RI Repeat interval
RP Reference pointer
SAD Street address
SCV Scheduling class value pair
SN Structured numeric
SRT Sort order
ST String data
TM Time
TQ Timing quantity
TS Timestamp
TX Text data
VH Visiting hours
VID Version identifier
XAD Extended address
XCN Extended composite ID number and name for persons
XON Extended composite name and identification number for organizations
XPN Extended person name
XTN Extended telecommunications number
Standards and Guidelines Reference Manual Appendix B: NCPDP Standards 51
Appendix B: NCPDP Standards
Overview
This section describes how to use NCPDP transactions in TIBCO
Foresight products.
The National Council for Prescription Drug Programs (NCPDP) has data interchange
standards for pharmacy services. NCPDP's Telecommunication Standard Version 5.1
and D.0 are supported by TIBCO Foresight validation products (EDISIM, HIPAA
Validator Desktop, and Instream). The batch transaction standard for enveloping is
Version 1.1 for HIPAA.
NCPDP in TIBCO Foresight Products
The NCPDP5 and NCPDPD0 guidelines are HIPAA-specific and so are distributed
with the following TIBCO Foresight products:
HIPAA Validator Desktop version 4.1 or later
Instream version 4.1 or later – validation (including Trading Partner Automation)
only.
You can use it with these modules of EDISIM 5.13 or later (copy NCPDP5.STD and
NCPDPD0.STD from Instream’s or HIPAA Validator Desktop’s Database folder to
EDISIM’s User Files\Public Guidelines directory:
EDISIM Standards Editor – including the ability to create rules
EDISIM Document Builder – creates X12-format output
EDISIM Comparator
EDISIM Standards Reference
NCPDP does not work with EDISIM’s Test Data Generator and Analyzer modules.
Standards and Guidelines Reference Manual Appendix B: NCPDP Standards 52
Sample Data and Instream Scripts
Instream HIPAA
Validator
Desktop
Filename Directory Notes
NCPDP_BillRequest_51.txt DemoData A Billing (Request)
containing three G1
segments, each with one
claim.
NCPDP_ Response _51.txt DemoData A B2 Billing Reversal
(Response) containing five
G1 segments, each
containing segment 21, a
Response Status Segment.
V_NCPDP_51_BillRequest Scripts Validates
NCPDP_BillRequest_51.txt.
Terminology
X12 NCPDP
Interchange Batch
Functional Group none
Transaction Set Transmission
Loop none
Claim or other application
document
Transaction
Segment Segment
Composite none
Element Element
Code Set none
Standards and Guidelines Reference Manual Appendix B: NCPDP Standards 53
Big Picture
Transaction Sets
Billing
B1 – Billing
B2 – Billing Reversal
B3 – Billing Rebill
Controlled Substance Reporting
C1 – Controlled Substance Reporting
C2 – Controlled Substance Reversal
C3 – Controlled Substance Rebill
Eligibility
E1 – Eligibility Verification
Information Reporting
N1 – Information Reporting
N2 – Information Reversal
N3 – Information Rebill
Prior Authorization
P1 – Prior Authorization Request and Billing
P2 – Prior Authorization Reversal
P3 – Prior Authorization Inquiry
P4 – Prior Authorization Request Only
Request or Response
Each transaction can be either a:
Transaction The originating request.
Response Acknowledgement of a request. Responses are prefaced with the
letter R in EDISIM. For example, the response to a B1 is an RB1.
Standards and Guidelines Reference Manual Appendix B: NCPDP Standards 54
Parts of a Batch
A batch contains these parts:
One 00 Transmission header segment with ISA-type information.
One or more G1 detail records, each containing one to four “transactions” such as
claims.
One 99 trailer containing a control number and segment count.
Codes
NCPDP doesn’t have actual code sets but the standard specifies allowed values. These
are implemented as code sets in TIBCO Foresight products.
Elements
The first value in a segment is AM followed by the segment tag.
Other elements can be in any order, except mandatory elements come before
optional elements.
Each element in the transaction sections of the batch (in the claim itself, for
example) starts with the Field Separator character (x1C). Elements in header
segments have no delimiters.
Leading zeroes and leading or trailing spaces are tolerated.
Elements in transaction segments have maximum lengths but no minimum lengths.
Elements in header segments are fixed length.
Values have two parts: a two-character element tag, and then data.
Element IDs
NCPDP element IDs can be in these formats.
nnn Only in batch control segments. Example: 303
nnn-aa The usual NCPDP element ID. The last two characters are called the element tag.
Standards and Guidelines Reference Manual Appendix B: NCPDP Standards 55
Since EDISIM and Library only allow up to four digits for element IDs, they are
abbreviated by taking out the third digit and the hyphen. Example: 101-7R becomes
107R in EDISIM. The description will include the full ID:
Element Types
Type As shown in
EDISIM
Notes
Code Lists ID These re values specified in the sta, not code lists
managed by outside organizations, as in X12.
Alphanumeric AN Data is left justified with spaces padded on the right. All
letters are uppercase.
Numeric N or Nn n is the number of implied decimal places. Do not include
explicit decimals in data. The sign is over punched in the
last digit (see chart below).
Data is right justified and zero filled.
Signed Values
To avoid expanding the size of a field, plus or minus characters are combined with the
last digit of data. The overpunch character replaces the right-most character.
Positive Example
To determine the EDI data for $19.95, look up the last digit (5) in the Value column of
the chart below. Now move to the right one column to find the value that would
represent 5 and signed positive is E. Therefore, the positive value $19.95 appears as
199E in the data, assuming the data type is N2.
Negative Example
To calculate the EDI data for minus $19.95, look up the last digit (5) in the Value
column of the chart below. Now move to the right until you find the column for signed
negative graphic. The value that represents 5 and signed negative is N. Negative $19.95
appears as 199N in the data.
Standards and Guidelines Reference Manual Appendix B: NCPDP Standards 56
Value Signed Positive Graphic Signed Negative Graphic
0 { }
1 A J
2 B K
3 C L
4 D M
5 E N
6 F O
7 G P
8 H Q
9 I R
Repeating Elements
Elements that can repeat are preceded by a count element containing the number of
repeating elements to follow.
If the Coordination of Benefits/Other Payments Count has a value of 2, the next
four elements cycle twice:
Standards and Guidelines Reference Manual Appendix B: NCPDP Standards 57
Segments
The segment separator is always hex 1E
The first segment in a batch is always the 00 Header segment, which is fixed length
without delimiters. It serves the same function as X12’s ISA.
The GIT segment that you see in TIBCO Foresight products is for requests. It
contains the reference number from the G1 segment, plus the elements from the
Request Header Segment QT. GIT is a TIBCO Foresight structure and is not part
of the standard.
The GIR segment that you see in TIBCO Foresight products is for responses. It
contains the reference number from the G1 segment, plus the elements from the
Response Header Segment RT. GIR is a TIBCO Foresight structure and is not part
of the standard.
Enveloping
The first segment in a batch is always the Transmission Header Segment, which serves
the same purpose as the X12 ISA. It starts with hex 02 followed by the 00 segment
identifier. It has fixed-length, required fields with no delimiters, and ends with hex 03.
Example (element IDs shown below):
Detail Segments
The G1 record starts with hex 02 followed by the segment ID G1 and then fixed-length,
undelimited fields in the Request Header Segment or Response Header Segment. It ends
with a hex 03.
The G1 record contains the application segments. These always start with the Segment
Separator character hex 1E, followed by AM and then the segment ID.
Within a G1, segments after the 07 segment are in any order. Likewise, within a segment,
elements can be in any order as long as mandatory elements come before optional
elements.
One G1 record can contain up to four claims.
Standards and Guidelines Reference Manual Appendix B: NCPDP Standards 58
Trailer Segment
The trailer record starts with a hex 02 and ends with a hex 03. All elements are fixed
length with no delimiters. It contains a batch number that should match the one in the
00 record, and a count of all 00, G1, and 99 records in the batch.
Example Batch
The following example is a request batch with three G1 segments, each with one claim.
Standards and Guidelines Reference Manual Appendix B: NCPDP Standards 59
Sample batch with three G1s
Batches always start with a 00 Transaction Set Header record. The control number is in
bold.
The T is the transmission type and indicates that the batch contains transactions
(requests) rather than responses.
Start of the first G1 record. Notice the B1, indicating that these will be Billing
transactions.
Start of the next G1 record.
Start of the 99 record, the trailer record. The control number is in bold and matches the
one in the 00 record. The last value in the 99 record is a count. It is 5 here: one 00 record, three
G1 records, and one 99 record.
Anatomy of a G1
The GI tag is immediately followed by the fixed-length elements in the Request Header
Segment (QH in TIBCO Foresight products) or the Response Header Segment (RH in TIBCO
Foresight products). This is underlined in the example. Each segment ends with a segment
terminator hex 1E, which displays as a hyphen in this example.
The mandatory 04 segment is next. Like all detail segments, it is preceded with AM.
Trailing spaces are optional and are shown in this example. Each element, including each
segment tag, begins with a hex ‘1C’. These display as boxes in the example above.
The conditional 01 segment is omitted in this example. The 07 segment is next and
begins the claim. This claim includes the 11 and 03 segments.
Standards and Guidelines Reference Manual Appendix B: NCPDP Standards 60
Data with no 1.1 “Enveloping”
Validation requires the 1.1 enveloping around the 5.1 data. This includes everything up
to and including the 10-digit transaction reference number after G1, and the 99 segment
at the end. The 1.1 areas are bold in the example below.
If your data does not have 1.1 enveloping, you can validate if you add the contents of a
header file to the beginning of your data and the contents of the trailer file to the end.
You can find these files in the DemoData directory of Instream and HIPAA Validator
Desktop:
File (DemoData
directory)
Contents Use if your data is …
HeaderTrans.NCPDP Beginning of the NCPDP transmission
file that has no 1.1 “enveloping”
A transmission
HeaderResponse.NCPDP Beginning of the NCPDP response file
that has no 1.1 “enveloping”
A response
Trailer.NCPDP End of the EDI file that has no 1.1
“enveloping”
Either transmission or
response
The data can have only one transmission (or set), and cannot have extraneous characters
like end-of-files or padding after the last element.
To determine whether your data is a transmission or response, look at the first few
characters:
Transmission If the data starts with six characters followed by 51 or D0 (as in
01262851B1OKA01 …), then it is a transmission and you can put the
contents of HeaderTrans.NCPDP in front of it and Trailer.NCPDP
after it.
Response If the data starts with 51 or D0 (as in 51B1OKA01 …), then it is a
response and you can put the contents of HeaderResponse.NCPDP in
front of it and Trailer.NCPDP after it.