HIPAA EDI Support

The purpose for this page is to provide support and assistance to users using EDIdEv Framework EDI with their HIPAA EDI X12 projects.  Please download, install and familiarize yourself with Framework EDI before downloading the sample programs on this web page.

HIPAA EDI Guidelines
HIPAA EDI guidelines can be found on Washington Publishing Company website at www.wpc-edi.com.

Standard Exchange Format (SEF) Files
The following SEF files are also used by the sample programs. (Please note: The SEF files listed below do not contain any addenda, however SEF files with addenda can be purchased at our eShop for $90.00 each.)

270_4010X092.SEF Eligibility, Coverage or Benefit Inquiry
271_4010X092.SEF Eligibility, Coverage or Benefit Information
276_4010X093.SEF Health Care Claim Status Request
277_4010X093.SEF Health Care Claim Status Notification
278_4010X094Request.SEF Health Care Service Review -  Request for Review
278_4010X094Response.SEF Health Care Service Review - Response to Request for Review
820_4010X061.SEF Payment Order/Remittance Advice
834_4010X095.SEF Benefit Enrollment and Maintenance
835_4010X091.SEF Health Care Claim Payment/Advice
837_4010X096.SEF Health Care Claim: Institutional
837_4010X097.SEF Health Care Claim: Dental
837_4010X098.SEF Health Care Claim: Professional

SEF files are machine readable files that contain the implementation guideline of Transaction Sets.  They basically contain the same information of the EDI guidelines that we view in pdf format; but SEF files are in a format that can easily be read and parsed by a computer.  FREDI-COM and FREDI-NET components takes advantage of SEF files to obtain the implementation guideline information so that they can parse, construct and validate corresponding  EDI files correctly.  

Even though a SEF file contains the implementation guidelines of an EDI Transaction Set, it does not however contain any mapping information to your existing system.  For example, a SEF file cannot tell which data element in an EDI file gets mapped to a certain field in your database.  Therefore, this 'mapping' has to be done in your program. 

Also, please note that none of the SEF files contain the .TEXT section, nor do they include external codes.

Example Programs
Below are example programs to demonstrate how one can easily use the Framework EDI component in a programming language to generate, translate and validate EDI files.

Visual Basic .NET sample programs using FREDI-NET Hybrid component to process outbound and inbound EDI files.

• X091Net - Generates and translates HIPAA EDI 835 Health Care Claim Payment/Advice
• X092Net - Generates and translates HIPAA EDI 270 Health Care Eligibility, Coverage or Benefit
• X095NetDB - Generates and translates a HIPAA EDI 834 X095 Benefit Enrollment and Maintenance
• X098NetDB - Generates and translates a HIPAA EDI 837 X098 Health Care Claim: Professional from/to a database

C# .NET sample programs using FREDI-NET Hybrid component to process outbound and inbound EDI files.

• CsharpGen270 - Generates HIPAA EDI 270 Health Care Eligibility, Coverage or Benefit
• CsharpTranAck270 - Acknowledges and translates HIPAA EDI 270 Health Care Eligibility, Coverage or Benefit
• CsharpGen837 - Generates a HIPAA EDI 837 X098 Health Care Claim: Professional 
• CsharpTran837 - Translates a HIPAA EDI 837 X098 Health Care Claim: Professional 

Visual Basic 6 sample programs that generate and translate HIPAA EDI files using Framework EDI.

• X061- Transaction Set 820. 
• X091- Transaction Set 835. 
• X092- Transaction Set 270/271. 
• X093- Transaction Set 276/277.
• X094- Transaction Set 278. 
• X095- Transaction Set 834. 
• X096- Transaction Set 837 - Institutional.  
• X097- Transaction Set 837 - Dental.  
• X098- Transaction Set 837 - Professional. 

Delphi 5 skeleton programs that uses Framework EDI

• DelphiX096Gen.zip - Generates an 837 X096 EDI file.
• DelphiX096Tran.zip - Translates an 837 X096 EDI file.

FoxPro 6 skeleton programs that uses Framework EDI

• FoxX095Tran.zip - Translates an 834 X095 EDI file.
• FoxX096Gen.zip - Generates an 837 X096 EDI file.
• FoxX096Tran.zip - Translates an 837 EDI file.
• FoxX096Db.zip (maps EDI 837X096 EDI file with  multiple claims into a database).

Visual C++ skeleton programs that uses Framework EDI 

• X096VC.zip - Generates and translates 837X096 EDI file.

Access - sample programs to demonstrate how one can map EDI files to/from a database

• AccessGenX096.zip - Generates an 837 X096 EDI file with multiple claims from a database.
• AccessTranX096.zip - Translates an 837 X096 EDI file with multiple claims to a database.
• AccessTranX091.zip - Translates an 835 X091 EDI file to a database.
• AccessGenX095.zip - Generates an 834 X095 EDI file from a database.
• AccessTranX095.zip - Translates an 834 X095 EDI file to a database.

Excel - demonstrates how to generate an EDI file from a spreadsheet

• ExcelGen834.zip - Generates an 834X095 EDI file from a spreadsheet.
• ExcelTran835.zip - Translates an 835X091 EDI file to a spreadsheet.

Framework EDI HIPAA EDI validation

Framework EDI validates an EDI file by checking it against the corresponding SEF file.  Any discrepancy between them will be regarded as an error in the EDI file.  Framework EDI can check for any expression that can be entered into the SEF file.  Validation includes the following types of testing recommended by WEDI SNIP (please visit their website for more information http://www.wedi.org/snip/ )

• Type 1: EDI syntax integrity testing
• Type 2: HIPAA syntactical requirement testing
• Type 4: Situational testing
• Type 5: External code set testing
  • (Please note that none of the SEF files provided by EDIdEv includes external codes)
• Type 6: Product types or line of services

Framework EDI does not automatically test Type 3: Balancing.  This test type would have to be implemented by the programmer at the time of translation.

For test Type 7: Implementation Guide-Specific Trading partners, programmers would have to create separate SEF files specific to the trading partners.

Example Validation Programs
Below are example programs to demonstrate how one can easily use the Framework EDI component in a programming language to validate a HIPAA EDI file and automatically create a Functional Acknowledgment (997).

Visual Basic 6

• Ack (Functional Acknowledgment sample program)
• ValidateHipaa (Sample program that validates HIPAA EDI files)

ASP.NET 

• Click here for ASP .NET sample programs of the Ack and ValidateHipaa

Visual C++

• X096AckVC - .Generates Functional Acknowledgment 997

Access

• AccessAckX091.zip - Generates Functional Acknowledgment 997 EDI file.

Note:  The correct version of SEF files must be used in both the "ValidateHipaa" and "Ack" sample program to generate a correct report and Functional Acknowledgment 997 file respectively.  Also, Framework EDI does not validate the calculations of an EDI file (e.g. total sum of ...).  To include this kind of test, you would have to do it programmatically.

For more information about Framework EDI's validation capabilities, please read EDI Validation.

Click here to download Framework EDI 

Other Topics

• Processing huge EDI files: Performance Test
• EDI to Database
• Overcoming EDI problems
• EDI Validation

If you have further questions or requests, please email support@edidev.com.

EDIdEv provides programming examples for illustration only, without warranty either expressed or implied, including, but not limited to, the implied warranties of merchantability and/or fitness for a particular purpose. This article assumes that you are familiar with the programming language being demonstrated and the tools used to create and debug procedures. EDIdEv  support engineers can help explain the functionality of a particular procedure, but they will not modify these examples to provide added functionality or construct procedures to meet your specific needs.

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