HIPAA Transaction Set Schemas

All HIPAA transaction set schemas are provided by Washington Publishing Company (WPC) and are represented as annotated XML-Data Reduced (XDR) document specifications in BizTalk Server.

The following features are new in BizTalk Accelerator for HIPAA 3.x:

  • Support for the X12N implementation guides adopted under HIPAA as amended in October 2002. Those amended implementation guides, still based on X12 version 004010, are referred to as "addenda" and are identified by the suffix "A1".

  • Support for two X12N implementation guides, not yet adopted under HIPAA, and based on X12 version 004020.

  • The ability to include X12 envelope information in the parsed XML document.

BizTalk Accelerator for HIPAA contains a special feature for document splitting. For more information, see Multiple Document Instances. In the following table, the schemas that contain the document-splitting feature are denoted by an X in the "multiple" column.

BizTalk Accelerator for HIPAA 3.3 contains the following schemas:

X12 transaction set identifier,

004010 single

004010 single envelope

004010 multiple

004010 multiple envelope

004010A1 single envelope

004010A1 multiple envelope

004020 single envelope

270 Eligibility, Coverage or Benefit Inquiry

X

X

 

 

X

 

 

271 Eligibility, Coverage or Benefit Information

X

X

 

 

X

 

 

275 Additional Information to Support a Health Care Claim or Encounter

 

 

 

 

 

 

X

276 Health Care Claim Status Request

X

X

 

 

X

 

 

277 Health Care Claim Status Response

X

X

 

 

X

 

 

277 Health Care Claim Request for Additional Information

 

 

 

 

 

 

X

278 Health Care Services Review - Request for Review and Response

X

X

 

 

X

 

 

820 Payment Order/Remittance Advice

X

X

 

 

X

 

 

834 Benefit Enrollment and Maintenance

X

X

X

X

X

X

 

835 Health Care Claim Payment/Advice

X

X

X

X

X

X

X

837 Health Care Claim: Professional

X

X

X

X

X

X

X

837 Health Care Claim: Dental

X

X

X

X

X

X

X

837 Health Care Claim: Institutional

X

X

X

X

X

X

X

Note  Envelope preservation is only available in BizTalk Accelerator for HIPAA 3.x as part of the HIPAA serializer. Because BizTalk Mapper calls the X12 serializer, it will not correctly process the interactive test of a native instance-to-native instance when envelope-enabled schemas are involved.

Note  Even though BizTalk Accelerator for HIPAA refers to templates, they should not be altered. You can use BizTalk Editor to modify the HIPAA-specific schemas supplied with BizTalk Accelerator for HIPAA. You should use caution when changing the schemas to ensure that you remain in compliance with various aspects of the HIPAA implementation guides.

For more information about the schemas, see the Microsoft BizTalk Accelerator for HIPAA 3.3 Transaction Set Reference Guide.

New in BizTalk Accelerator for HIPAA 3.3 is a collection of sample electronic data interchange (EDI) documents used for testing purposes to validate run-time compliance. The samples consist of a batch-oriented and an individual-oriented sample for each transaction and can be found in \Program Files\Microsoft BizTalk Accelerator for HIPAA\Samples\Test Data.

Note  The EDI subsystem determines which 837schema type to use, by analyzing a the REF02__TransmissionTypeCode tag.

This Tag can be populated with three possible values, namely:

004010X096 meaning this is an Institutional schema type. 004010X097 meaning this is a Dental schema type.

004010X098 meaning this is a Professional schema type.

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