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Electronic Data Interchange Assessment Strategies

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sevilen-osman
15 diapositives · 297 Views · Nov 04, 2014

This guide covers essential strategies for assessing and implementing Electronic Data Interchange (EDI) systems in healthcare. It explores application systems, trading partners, and business associates, detailing the necessary steps for compliance with HIPAA and EDI standards. The document also examines vendor management, system modifications, testing versus certification, and outlines various EDI transaction types. Detailed resources, standards, and agreements are provided to ensure a successful EDI strategy, including case studies and guidance on reviewing contracts and agreements for compliance.

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  1. Electronic Data Interchange Assessment Strategies • Application Systems • Trading Partners • Business Associates • Application Vendors • The Standards • Application System Modifications • Testing vs. Certification • Implementation

  2. Application Systems • What is an Application System? • Inventory Application Systems • Determine Owner • In-house vs. Vendor Supported • Assess Application System • Transactions, Medical Code Sets, National Identifiers • Utilize ‘System Functionality Statement’ as a Starting Point

  3. Trading Partners • What is a Trading Partner? • Inventory Trading Partners • Review Trading Partner Agreements • Form New Trading Partner Agreements WEDI/SNIP White Paper http://snip.wedi.org/public/articles/Trading113000.pdf

  4. Business Associates • What is a Business Associate? • Inventory Business Associates • Review Business Associate Agreements • Modify Agreements for HIPAA • Form New Business Associate Agreements • Follow-up with Business Associate • Company HIPAA Statements and Status • Compliance Strategies

  5. Application Vendors • Review Application Vendor Contracts • Governmental Mandates • Maintenance Fees • Version Upgrade vs New Development • Follow-up with Application Vendor • Company HIPAA Statements and Status • Compliance Strategies

  6. The EDI Standards • What is a Standard? • Who has to use the Standards? • When are the Standards Required?

  7. The EDI Standards • Health Care Eligibility Benefit Inquiry and Response • ASC X12N 270/271 (004010X092) • Health Care Claim Status Request and Response • ASC X12N 276/277 (004010X093) • Health Care Services Review Request and Response • ASC X12N 278 (004010X094) • Benefit Enrollment and Maintenance • ASC X12N 834 (004010X095)

  8. The EDI Standards • Payroll Deducted and Other Group Premium Payment for Insurance Products • ASC X12N 820 (004010X061) • Health Care Claim • Institutional (UB92) • ASC X12N 837 (004010X096) • Professional (HCFA1500) • ASC X12N 837 (004010X098) • Dental • ASC X12N 837 (004010X097) • Health Care Claim Payment/Advice • ASC X12N 835 (004010X091)

  9. The EDI Standards Washington Publishing Company ANSI ASC X12N HIPAA Implementation Guides http://hipaa.wpc-edi.com/HIPAA_40.asp

  10. Application System Modifications • Assess Further at Data Element Level • Compare Data Elements to the Standards • Mandatory • Situational • Conditional • Compare Data Element Attributes • Numeric, Alpha, Alphanumeric, Size • Review Business Needs • ‘have’ vs. ‘don’t have’ vs. ‘cannot have’

  11. Application System Modifications • Determine Business Specifications • How to do Business the HIPAA way • Business and IT Unite • IT cannot ‘Fix’ HIPAA • Require Business Decisions • Involve All Interested Parties • Application System Users • Management • Worker Bees

  12. Testing vs. Certification “Those attempting to ‘self-certify’ are simply testing themselves from beginning to end.” • Testing • Application Systems • Internal • Application to Application (A2A) • Files, Program Code, Edits, Reports, Financials, etc... • External • Business to Business (B2B) • Transactions

  13. Testing vs. Certification • Certification • Electronic Healthcare Network Accreditation Commission (EHNAC) • http://www.ehnac.org/ • Claredi • http://www.claredi.com WEDI/SNIP White Paper http://snip.wedi.org/public/articles/testing030901.pdf

  14. Implementation • Trading Partner Agreements In Place • Business Associate Agreement In Place • Application Systems HIPAA Compliant • Training Completed and Ongoing • Internal Testing Completed • External Testing Completed • HIPAA Transaction Certification Obtained • Now to the Second Phase

  15. HIPAA PMO EDI Team Cynthia Wagoner, PMO EDI Lead • cynthia.wagoner@ncmail.net • 919-661-5883 Stephen Fraser, PMO EDI Technical Writer • stephen.fraser@ncmail.net • 919-661-5892 Marilyn Tarkalson, PMO Administrative Assistant • marilyn.tarkalson@ncmail.net • 919-661-5897 http://dirm.state.nc.us/hipaa/newsite/focusgroup/edi/edi.html