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Advanced Technical Concepts

Advanced Technical Concepts

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Advanced Technical Concepts

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  1. Advanced Technical Concepts 2008 IAIABC All Committee ConferenceApril 7-12, 2008 Austin, TX

  2. IAIABC EDI Training Team Your Trainers: • Robbie Tanner email: rtanner@iso.com Assistant Director WC Network Products, ISO IAIABC Participation: • EDI Systems • EDI XML Work Group Leader • EDI Claims • EDI Proof Of Coverage • EDI Medical • EDI Trainer

  3. IAIABC EDI Training Team Your Trainers: • Lori Raby email: lraby@roesinc.com IT Business Analysis Consultant – Ingenix/ROES IAIABC Participation: • EDI Systems Committee Vice Chair • EDI Claims • EDI XML • EDI Proof Of Coverage (POC) • EDI Medical • EDI Triage • EDI Trainer

  4. IAIABC EDI Training Team Your Trainers: • Sharon Marion email: smarion@peakpsi.com EDI Coordinator – Peak Performance IAIABC Participation: • EDI Systems Committee Chair • EDI XML • EDI Medical • EDI Claims • EDI Trainer

  5. EDI 301 Transactions/Records (Fixed and Variable Length)

  6. Transaction A Transaction consists of 1 or more ‘records’ to communicate an event such as a claim event or policy event.

  7. Record • A recordis a group of ‘related data elements’ (which is a single piece of information) that form a transaction. • Some records are fixed length and some are variable length.

  8. A fixed length record is consistently the same number of data positions each time the record is assembled. Fixed Length Records Based on the individual record layout, the data within the record is always in the same position.

  9. A variable length record may varyeach time the record is assembled. Variable Length Record The variable length record has a minimum record length and based on the occurrence of the data being reported, a maximum record length.

  10. IAIABC Release 1 Records Technically identified by DN0001-Transaction Set ID Release 1 records are either fixed orVariable length.

  11. IAIABC Release 3 Records Technically identified by DN0001-Transaction Set ID Release 3 records are either fixed orVariable length.

  12. EDI 301 Batches/Transmissions

  13. Batch Each Transaction Type (transaction) is contained in a batch which ispreceded by a Header Record and concluded with a Trailer Record. Header Transactions Trailer

  14. The Header Record (HD1) • precedeseach batch of data. It is the first record in every batch • uniquely identifiesinformation about the batch and the data within the batch Batch • along with the Trailer Record forms an“envelope”that surrounds a batch of transactions

  15. Transactions • A Transactioncan consist of 1 or more ‘Records’ to report a claim event.

  16. 148 A49 Release 1uses 1 Recordper Transaction to report a claim event. 148 = FROI A49 = SROI

  17. A49 Release 3 requires 2 records per transaction to report a claim event. 148 + R21 = FROI 148 R21 A49 + R22 =SROI R22

  18. Release 3records DN0015 - Claim Administrator Claim Number is populated in all Release 3 FROI and SROI records. 148 R21 A49 This “links” the companion record to its related 148 or A49 record. R22

  19. Acknowledgment Transactions Both Release 1 and Release 3 Acknowledgment transactions use 1 record to communicate an event.

  20. The Trailer Record • designatesthe endof a batch of transactions • providesa countof records/transactions within a batch • is used to ensure that the entire batch iscomplete and valid • along with the Header record completes the“envelope”that surrounds a batch of transactions

  21. FROI Transactions Batch example of R1 FROI transactions 8 records = 8 transactions Header 148 Record 1 148 Record 2 B A T C H 148 Record 3 148 Record 4 148 Record 5 148 Record 6 148 Record 7 148 Record 8 Trailer

  22. SROI Transactions Batch example of R1 SROI transactions 8 records = 8 transactions Header A49 Record 1 A49 Record 2 B A T C H A49 Record 3 A49 Record 4 A49 Record 5 A49 Record 6 A49 Record 7 A49 Record 8 Trailer

  23. 148 Record 1 R21 Record 2 148 Record 3 R21 Record 4 148 Record 5 R21 Record 6 148 Record 7 R21 Record 8 FROI Transactions Batch example of R3 FROI transactions 8 records = 4 transactions Header B A T C H Trailer

  24. A49 Record 1 R22 Record 2 A49 Record 3 R22 Record 4 A49 Record 5 R22 Record 6 A49 Record 7 R22 Record 8 SROI Transactions Batch example of R3 SROI transactions 8 records = 4 transactions Header B A T C H Trailer

  25. FROI Header FROI FROI FROI Transactions FROI FROI FROI FROI Trailer FROI Header SROI SROI SROI SROI Transactions SROI SROI SROI Trailer Components of a Transmission B A T C H BATCH:Consists of 1 Header record, one or more Transactions and 1 Trailer record. B A T C H

  26. FROI Header FROI FROI FROI Transactions FROI FROI FROI FROI Trailer FROI Header SROI Transactions Trailer Components of a Transmission B A T C H TRANSMISSION:Consists of 1 or more batches sent or received during a communication session. TRANSMISSION B A T C H SROI SROI SROI SROI SROI SROI

  27. Questions?

  28. EDI 301 Data ElementFormats

  29. Data Element • Data Element:A single piece of information. The Data Dictionary in the Implementation Guide provides the definitions, format, valid values and population rules for each data element.

  30. Data Dictionary Example Specific Data Element Information

  31. Data Element Formats Dates: Type = DATE (CCYYMMDD):Data elements that are assigned the format of DATE should be populated with only a valid date. Example: December 1, 2001 should be populated with 20011201.

  32. Data Element Formats Dates: Type = DATE: CCYYMMDD All zeros in a date field are considered to be invalid data. = invalid data ‘00000000’   Spaces indicate absence of data.

  33. Data Element Formats Time: Type = TIME:Data elements that are assigned the format of TIME should be populated with only a valid 24-hour military time. 11:54 pm

  34. Data Element Formats Time: Type = TIME: The valid values for military time are 000000 (midnight) through 235959 (11:59:59 p.m.). Example: HHMMSS: 142903 = 2:29:03 P.M. Spaces indicate absence of data.

  35. Data Element Formats Numeric: Type = N:Data elements that are assigned the format of N should be populated with only a valid numeric character.

  36. Data Element Formats Numeric: Type = N: Valid values consist of 0 - 9 and are right justified zero filled to the left. Example: 3 numeric ‘123’ in 6 byte field = 000123 123 000 Spaces indicate absence of data.

  37. Data Element Formats Monetary Amounts: Type = $9.2:Data elements that are assigned the format of $9.2 should be populated with only a valid monetary amount.

  38. Data Element Formats Valid entries consist of eleven numeric digits with the dollar sign assumed and the decimal point between the ninth and tenth position assumed. Monetary Amounts: Type = $9.2: Example: 00000005000 = $50.00 0000000 50 00 $ ^ Spaces indicate absence of data.

  39. Data Element Formats Percentage: Type = 3.2:Data elements that are assigned the format of 3.2 should be populated with only a valid percentage. 125%

  40. Data Element Formats Percentage: Type = 3.2: Valid entries consist of 0 - 9 and are right justified zero filled to the left. Example: 50.00% = 05000 ^ The decimal point is assumed between the third and fourth position. Spaces indicate absence of data.

  41. Data Element Formats Alphanumeric: Type = A/N:Data elements that are defined the format of A/N consist of a sequence of any characters from common character code schemes (EBCDIC, ASCII, and CCITT International Alphabet 5).

  42. Data Element Formats When using an alphanumeric field, the significant characters are always left justified in the field with any remaining space in the field padded with spaces. Alphanumeric: Type = A/N: SMITH (spaces)

  43. Data Element Formats Alphanumeric character set includes those selected from the uppercase letters, lower case letters, numeric digits, space character, and special characters. Alphanumeric: Type = A/N: See System Rules of the R3 Implementation Guide. Spaces indicate absence of data.

  44. EDI 301 Release 1Transactions/Records

  45. HD1 – Release 1 Header Record There are 9 data elements and the record is 87 bytes fixed length

  46. HD1 – Release 1 Header Record uniquely identifiesthe sender, the receiver, the date and time batch was prepared

  47. HD1 – Release 1 Header Record whether the batch contains test or production data and the Transaction type

  48. 148 - Release 1 FROI Record913 Byte Fixed Length Record

  49. TR1 – Release 1 Trailer Record12 Byte Fixed Length Record