Below are transaction standards and related code sets that apply under HIPAA:

Transactions
ASC X12N

• ASC X12N 837-Health Care Claim: Dental
• ASC X12N 837-Health Care Claim: Professional
• ASC X12N 837-Health Care Claim: Institutional
• ASC X12N 270/271-Health Care Eligibility Benefit Inquiry and Response,
• ASC X12N 278-Health Care Services Review÷Request for Review and Response
• ASC X12N 276/277 Health Care Claim Status Request and Response
• ASC X12N 834-Benefit Enrollment and Maintenance
• ASC X12N 835-Health Care Claim Payment/Advice
• ASC X12N 820-Payroll Deducted and Other Group Premium Payment for Insurance Products

X12 Standards are required for all HIPAA transactions except for pharmacy claims, for which standards developed by the National Council for Prescription Drug Programs (NCPDP) have been adopted.

Select Code Sets
Foresight includes all code sets designated by the HIPAA Implementation Guidelines, including:

• Diagnoses and inpatient hospital services: International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM)
• Institutional Services: ICD-9-CM, Volume 3 and HCFA Common Procedural Coding System (HCPCS)
• Physician Services: Current Procedural Terminology (CPT)
• Dental Services: Current Dental Terminology (CDT)
• Drugs: National Drug Code (NDC)

Coming soon: A standard for "attachments" and additional standard transactions.

Types 1-7
The Strategic National Implementation Process (or SNIP, the group constituted under the Workgroup for Electronic Data Interchange to guide the health care industry in an orderly implementation of HIPAA-compliant EDI) has recommended transaction testing prior to "going live" with standard format transactions. SNIP has recommended the following types (categories) of testing:

Type 1: Integrity Testing (X12 Syntax)
Testing for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 syntax and compliance with X12 rules.

Type 2: Requirement Testing (Implementation Guide Syntax)
Testing for HIPAA implementation Guide (IG)-specific requirements, such as repeat counts, codes included and omitted, elements and segments, required or intra-segment situational data elements, and values noted in the IG via an X12 code list or table.

Type 3: Balancing
Testing the transaction for balanced field totals, record or segment counts, financial balancing of claims or remittance advice, and balancing of summary fields

Type 4: Situation Testing (Implementation Guide "Situational Elements")
Testing specific inter-segment situations described in the IG’s such that: If A occurs, then B must be populated. This is considered to include the validation of situational fields given values or situations present elsewhere in the file.

Type 5: Code Set Testing
Testing for valid implementation-guide-specific code set values.

Type 6: Specialty or Line of Business Testing
Product Types/Types of Service testing or line-of-business testing is specialized testing required by certain health care specialties.

Type 7: Trading Partner-Specific Testing
Trading Partner-Specific testing that enables trading partners to specify requirements for partners per the Implementation Guides, such as Medicare and Indian Health.

Partner Edits
Edits that a payer suggests that enable partners to pass a payer’s adjudication system.

 
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