HIPAA Implementation Guide v5

7/17/2019 HIPAA Implementation Guide v5

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Oracle Enterprise HCM HIPAA Implementation

Table of Contents:

Overview..................................................................................................................................................2

Design Approach.................................................................................................................................2

Glossary...............................................................................................................................................3Provider/Vendor Changes........................................................................................................................4

Benefi Plan Changes...............................................................................................................................4

!D" #34 $ransacion %ap $a&le..............................................................................................................'

!nroll(en )napsho Opions..................................................................................................................*!D" $rading Parners...............................................................................................................................#

Creae +"PAA !D" #34 ,ile -n Conrol..............................................................................................

%iscellaneos ,ile Changes..................................................................................................................4

289646641.doc Oracle Proprietary and Confidential 1


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Overview

$he crren +"PAA #34 i(ple(enaion0 &ased off of he A1)" "(ple(enaion Gide0 is only availa&le as a fllfile andhas very lile vendorspecific cso(i5aions availa&le. $here is a high de(and for he creaion of he +"PAA file on an

6pdae only &asis0 as reco((ended &y he gide. "n addiion0 cso(ers have &een re7esing a wide range of changes o

he process o acco((odae vendorspecific variaions.

$he +"PAA #34 file creaion process has &een (odified o provide 6pdaeonly file capa&iliies and o acco((odae (any

of he variaions ha have &een re7esed &y cso(ers. $he changes (ade (ainain overall co(pliance wih he A1)"

for(a and refrain fro( Vendorspecific0 nonconfor(ing i(ple(enaions.

Design Approach

)ince his is designed as a posing0 he approach a8en is one ha provides he (ini(al fncionaliy re7ired wih a (ini(al

i(pac and ris8 for he cso(ers. $o deer(ine he (ini(( re7ire(ens0 so(e ass(pions and li(iaions have &een

(ade in he design of his fncionaliy. $hey are he following9

All changes will &e co(plian wih he A1)" #34 "(ple(enaion Gide :Benefi and !nroll(en %ainenance #34

A)C ;21 #34 :


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Glossar

HIPAA +ealh "nsrance Pora&iliy and Accona&iliy Ac of ==@.

ANSI A(erican 1aional )andards "nsie.

EDI !lecronic Daa "nerchange.

X12 A(erican 1aional )andards "nsie Accredied )andards Co((iee elecronic daa inerchange sandard.

Sponsor A sponsor is he pary ha li(aely pays for he coverage0 &enefi0 or prodc. A sponsor can &e an e(ployer0

nion0 govern(en agency0 associaion0 or insrance agency.

Payer/Insurer $he payer is he pary ha pays clai(s and/or ad(inisers he insrance coverage0 &enefi0 or prodc. A

payer can &e an insrance co(pany +ealh %ainenance Organi5aion :+%O> Preferred Provider Organi5aion :PPO> a

govern(en agency0 sch as %edicare or Civilian +ealh and %edical Progra( of he 6nifor(ed )ervices :C+A%P6)> or

anoher organi5aion conraced &y one of hese grops.

Participant or member or insured An individal associaed wih an enroll(en. $hese individals can &e s&scri&ers:sally e(ployees>0 or covered dependens.

Subscriber $he s&scri&er is an individal eligi&le for coverage &ecase of his or her associaion wih a sponsor. !a(ples

of s&scri&ers inclde he following9 e(ployees0 nion (e(&ers0 and individals covered nder govern(en progra(s0 sch

as %edicare and %edicaid.

Dependent A dependen is an individal who is eligi&le for coverage &ecase of his or her associaion wih a s&scri&er.

$ypically0 a dependen is a (e(&er of he s&scri&ers fa(ily.

External Tradin Partner:receiver> !niy receiving he #34 ransacion se rans(ission.

Internal Tradin Partner:sender> !niy sending he #34 ransacion se rans(ission.

Implementation !uide "niial Daa -e7ire(ens0 A)C ;2.#34 "(ple(enaion Gide :;doc(en0 (enioned a&ove.



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Provi!er"#en!or Changes

$he Grop 1(&er field has &een epanded fro( < characers o 3< characers on he Provider/Vendor a&le. $he Grop1(&er vale is rans(ied in he +"PAA file and sppors he epanded lengh.

Example" :field affeced is highlighed in red>-!,E234@*#'@*#FNa#iation" )e 6p +-%) Prodc -elaed Base Benefis Plans and Providers Provider/Vendor $a&le

$enefit Plan Changes

$he Benefi Plan $a&le incldes wo new fields.

EDI Plan $o#erae Description

$he !D" Plan Coverage Descripion field :A/1 ' has &een added o he Benefi Plan $a&le as an opional field. Any vale

ha is enered in he field is inclded in he +"PAA file in posiion +D

Current HD segment:

+D


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EDI %&' Transaction Map Table

)everal changes have &een (ade o he !D" #34 $ransacion %ap $a&le.

&arital Status

%arial )as has &een added as a field o he a&le and several eising sas (appings are delivered as seen &elow. $he

%apped field vale for he %arial sas will &e inclded in he D%G


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De'ault EDI $ode

A Defal !D" Code chec8&o has &een added o he Plan $ype (appings as shown &elow. !ach Plan $ype will have one

defal !D" code &ased on he crren defal +D


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Enrollment (napshot Options

$he eising "nclde "(plied $er(inaions chec8&o was rena(ed o "nclde "(plied !(ployee $er(inaions on he!nroll(en )napsho Opions page. $his fncions as i did &efore. $he change was (ade o (a8e i clear ha i only referred

o i(plied !(ployee er(inaions.

A new chec8&o has &een added na(ed "nclde "(plied Dependen $er(inaions. ?hen seleced0 he syse( creaeser(inaion records for dependens in he snapsho and repors he( in he +"PAA file when here is a er(inaion for an

!(ployee ha also er(inaed he dependen or when a new coverage row has &een added for an !(ployee and a dependen

ha was previosly covered has &een dropped fro( coverage.

Note""nclde "(plied Dependen $er(inaions chec8&o fncionaliy only wor8s when he "nclde "(plied !(ployee

$er(inaions chec8&o is also chec8ed.

Example"S'ouse record with a termination date o! *+*,,,

"1)1


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EDI Tra!ing Partners

)everal addiional fields have &een added o he !D" $rading Parners sep page. $heir fncionaliy is deailed &elow.

Na#iation" )e 6p +-%) Prodc -elaed Base Benefis !D" $rading Parners

Application (ecei#er)s $ode

An Applicaion -eceivers Code field :A/1 '> has &een added o he !D" $rading Parners page. $his vale is sed opoplae he G)

IS- . %S segments using the de!aults / &0ternal ID = +1234567, . Internal ID = ,7654321+:

")A


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IS- . %S segments with &0ternal ID = +1234567,8 Internal ID = ,7654321+8 -'' Senders Code = . -''

9eceiver"s Code = 11111:

")A


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Examples" :new seg(en is highlighed in red>

I! Master Polic


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Create HIPAA EDI %&' )ile *+n Control

%liple fields have &een added o he +"PAA !D" -n Conrol. $heir fncionaliy is deailed &elow.

Na#iation" Benefis "nerface wih Providers Creae +"PAA !D" #34 ,ile

+ile E''ecti#e , +ile Enrollment Dates

$wo new dae fields have &een added o he +"PAA !D" -n Conrol. ?hen eiher of he daes have &een enered in he -nconrol0 he corresponding D$P seg(en:s> is creaed and sen in he file. $he ,ile !ffecive Dae vale is sen in a D$P

seg(en wih he Dae Kalifier of


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Examples" :new seg(ens are highlighed in red>

I! >ile &!!ective date = +**,,48 and >ile &nrollment date = *+*,,48 then the header segment =

BG1


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pdate 0nly +ile" $his file ype creaes a file ha conains only hose records where changes have occrred o eiher he

)&scri&er or any of his/her dependens records ha are relevan o he vendor and can &e rac8ed in +-%) hrogh he se

of effecive daes. $hese inclde changes sch as adding coverage0 changing a coverage code0 an address change0 a PCP

change0 a change in he covered dependens0 a change in Ho& sas :fro( acive o reiree>0 and er(inaions. Changes (adeo he Ho& record ha have no effec on +ealh &enefis :sch as a salary change> are no inclded in he file.

?hen he 6pdae Only ,ile file ype is seleced0 he ,ro( Dae and $o Dae fields appear and are re7ired. $he $o Dae

will ao(aically &e se o he snapsho As Of Dae. $his dae range will filer he change records o only inclde hose(e(&er records ha had changes wihin he dae range. Benefi enroll(en records will se he !lecion Dae as he dae

ha he change was (ade. $his will allow for &ac8daed changes in addiion o fre changes o &e inclded in he file.

Note"Any changes ha are done in Correc +isory (ode will no ao(aically rigger an pdae o &e sen. $he pdaewill only &e sen for ha record if and when he !lecion dae :for Benefis changes> or he !ffecive Dae :for No& and

Personal "nfor(aion changes> for he record falls wihin he dae range of he 6pdae ,ile.

?henever he s&scri&er or any (e(&er of a s&scri&ers fa(ily has a change0 he co(plee record:s> for all relevan(e(&ers of he fa(ily will &e sen in he file :inclding (e(&ers wih no changes>.$he (e(&ers daa sen in he file willalways &e he daa ha is effecive as of he dae of he Benefis )napsho0 even if (liple changes have &een (ade o a

(e(&ers record wihin he dae range.

$he BG1 and he "1) seg(ens will &e (odified o indicae he file ype and he ype of change (ade o he record asappropriae.

$he following a&le incldes changes in Benefis0 No& and Personal daa ha will or will no &e inclded in an 6pdae only

file per release. $he differences in he wo releases are de o he effecivedaing logic for dependens ha is inclded in #.=.

$anes included in pdate 'ile 3 34

Benefis Daa 1ew !nroll(ens L L

Coverage Code L L

Benefi Plan L L

Pri(ary Care Physician :PCP> L L

Covered Dependens L L

Plan $er(inaions L L

No& )as No& $er(inaion0 $er( wih Benefis0 $er( wih Pay L L

+ire0 -ehire L L

-eire(en0 -eire(en wih Pay L L

Personal Daa !(ployee Address L L

!(ployee %edicare )as L L

!(ployee 1a(e Change L L

!(ployee %arial )as L L

!(ployee Gender 1 1

!(ployee )(o8er )as L L

!(ployee Birh Dae 1 1

Dependen )den )as L L

Dependen Address 1 L

Dependen %edicare )as L L

Dependen 1a(e Change 1 L

Dependen Gender 1 1

Dependen )(o8er )as 1 L

Dependen Birh Dae 1 1



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Miscellaneo+s )ile Changes

Suppression o' HD and DTP Termination (o* 5under certain conditions6

Crrenly0 if an !(ployee changes heir Benefi Plan enroll(en o a new Benefi Plan ad(inisered &y he sa(e Vendor0 wo+D and D$P rows appear in he file0 one wih he new enroll(en and one wih he er(inaion of he prior Benefi Plan.

$he op file has &een (odified o sppress he +D and D$P er(inaion row for he old plan when he Vendor and he

Grop 1(&er for &oh he old and new Benefi Plans are idenical. "f he Vendor and/or Grop 1(&ers are differen for he

wo Benefi Plans0 hen he +D and D$P rows for &oh he new enroll(en and he er(inaion will appear in he file.

Examples":fields affeced is highlighed in red>

HD and D@P segments !or &m'loee who changed his Aision 'lan to a new 'lan with the same Aendor and a di!!erent %rou'


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"1)1=I! Hire date = *+3*+7778 then Memer segments =

"1)L#


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I! Medicare #egin date = +*+*,,48 then Memer segments =

"1)L#

HIPAA Implementation Guide v5

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