standards and guidelines reference manual

TIBCO Foresight® Studio®

Standards and Guidelines Reference

Manual

Software Release 9.0

August 2019

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Standards and Guidelines Reference Manual Contents i

Contents

Introduction 1

Overview .......................................................................................................................... 1 Basic Concepts ................................................................................................................ 1 XML and Flat-File Guidelines .......................................................................................... 2

Guideline Management with TIBCO Foresight Products ................................................. 2

Guideline Merging with GuideMerge ............................................................................... 4

Standards Overview 5

Overview .......................................................................................................................... 5

Supported Standards 7

Overview .......................................................................................................................... 7

Pre-X12 Standards .......................................................................................................... 8 X12 Standards ................................................................................................................. 8

X12 Derivatives .............................................................................................................. 10 Medical Standards ......................................................................................................... 10 EDIFACT Standards ...................................................................................................... 11

EDIFACT Derivatives ..................................................................................................... 13

Other Standards............................................................................................................. 13 XML Standards .............................................................................................................. 13 Flat-File Standards ........................................................................................................ 13

Guideline Overview 15

Overview ........................................................................................................................ 15

Life Cycle of a Guideline ................................................................................................ 16

Anatomy of a Guideline 21

Overview ........................................................................................................................ 21 Explanation for Segment Table Example ...................................................................... 24

Explanation for Segment Detail Page Example ............................................................. 27

Supported Guidelines 29

Overview ........................................................................................................................ 29 HIPAA Guidelines .......................................................................................................... 32 Healthcare Guidelines Non-HIPAA Mandated ............................................................... 38 Healthcare Guidelines for TIBCO Foresight® Community Manager® .......................... 41 General Guidelines ........................................................................................................ 42

Standards and Guidelines Reference Manual Contents ii

Appendix A: HL7 Standards 43

Overview ........................................................................................................................ 43 HL7 in TIBCO Foresight Products ................................................................................. 43 Sample Data and Instream Scripts ................................................................................ 44 Big Picture ...................................................................................................................... 45

HL7 Specific Information ................................................................................................ 46 HL7 Data Types ............................................................................................................. 49

Appendix B: NCPDP Standards 51

Overview ........................................................................................................................ 51 NCPDP in TIBCO Foresight Products ........................................................................... 51

Sample Data and Instream Scripts ................................................................................ 52

Terminology ................................................................................................................... 52

Big Picture ...................................................................................................................... 53 Codes ............................................................................................................................. 54 Elements ........................................................................................................................ 54 Segments ....................................................................................................................... 57

Example Batch ............................................................................................................... 58 Data with no 1.1 “Enveloping” ........................................................................................ 60

Standards and Guidelines Reference Manual Introduction 1

Introduction

Overview

This document is intended as a reference for those who use EDI industry standards

and guidelines or develop customized guidelines using TIBCO Foresight® products.

Basic Concepts

Standards

Standards ensure that electronic data conforms to formatting rules for sending

business documents between companies using delimited, variable-length fields.

Some well-known standards are X12, EDIFACT, and NCPDP.

Industry Guidelines

Industry guidelines further define rules for specific industries.

Examples of types of industry guidelines are those related to healthcare, pharmacies,

and transportation logistics.


Customized Guidelines

Customized guidelines are those you develop using a published standard or guideline

as a starting point. They further define rules in places where the standard or industry

guideline is not specific enough or you need specialized behavior. Customized

guidelines are also referred to as companion guidelines.

Production Guidelines

Production guidelines are guidelines for TIBCO Foresight® Instream® and TIBCO

Foresight® HIPAA Validator Desktop® that you create by merging a user guideline

with a TIBCO Foresight guideline.

XML and Flat-File Guidelines

Unlike EDI, XML and flat-file guidelines are not firmly based on standards.

Therefore, you will notice differences in how they are implemented in TIBCO

Foresight products. For more information refer to the following documents:

Using XML (XMLatForesight.pdf)

Using Flat Files (FlatFilesAtForesight.pdf)

Guideline Management with TIBCO Foresight Products

All TIBCO Foresight products

Read guidelines from their databases (.STD files)

List guidelines so that you can select one.

Foresight products also have specific roles when working with guidelines:

Foresight Product Role of Product Role of Guideline

TIBCO Foresight® EDISIM®

Allows you to build, publish, and test companion guidelines for use during EDI transaction processing and validation.

Create company guidelines

Uses guidelines to print documentation, make test data, validate types 1, 2, and 8, migrate guidelines to new version, view parts of guideline


Foresight Product Role of Product Role of Guideline

HIPAA Validator Desktop®

Validates data according to industry standards, custom guidelines, and specific business rules.

Provides the ability to correct data.

Uses guidelines to validate data types 1-8 (one file at a time)

Instream® Validates data according to industry standards, custom guidelines, and specific business rules.

Use guidelines to validate data types 1-8 (production)

TIBCO Foresight® Transaction Insight®

Enterprise-wide, partner-specific, and detailed transaction reporting and alerts

Advanced search and transaction matching capabilities

Ability to view, share, and correct transactions.

Uses guidelines to collect statistics, view, and correct EDI errors.

TIBCO Foresight® Community Manager®

Ability to check data against guidelines supplied by the Community Manager administrator.

Ability to view and download analysis results.

Uses guidelines to allow partners to validate their own EDI – types 1-8.


Guideline Merging with GuideMerge

Production guidelines are guidelines for Instream and HIPAA Validator Desktop

that you create by merging a user guideline with a TIBCO Foresight guideline.

HIPAA-based Production guidelines contain type 1-7 edits.

GuideMerge installs with HIPAA Validator® Desktop, EDISIM®, and Windows

versions of Instream.

Guideline Merge lets you merge the changes that you have made to your

guideline in EDISIM Standards Editor with:

TIBCO Foresight-supplied guidelines containing other HIPAA rules

Another EDI or flat file guideline with the same structure.

This lets you have a “master” guideline and then separate guidelines with

additional rules for specific partners, for example.

The parties in a merge are:

Master Spoke Production + =

The guideline that

determines the structure of

the result. All objects

(segments, loops,

elements, etc.) in this

guideline will go into the

production guideline.

The guideline used to

tweak the master

guideline. It should

have the same basic

structure as the

master.

The new guideline

created by the

merge.

Standards and Guidelines Reference Manual Standards Overview 5

Standards Overview

Overview

Standards ensure that electronic data conforms to formatting rules for sending

business documents between companies using delimited, variable-length fields.

Standards can contain many different transaction types. For example X12 standards

provide rules for hundreds of different transactions, often known by their numbers,

like these common ones:

810 Invoice

850 Purchase Order

856 Shipping Notice

997 Functional Acknowledgement

999 Acceptance/Rejection Advice

Supported Standards on page 7 provides a detailed list of the standards and

guidelines that TIBCO Foresight products support at some level.

Standards and Guidelines Reference Manual Supported Standards 6


Supported Standards

Overview

This section provides a listing of the standards:

Supported by EDISIM, Instream, and HIPAA Validator Desktop. (A note

may indicate partial support.)

Shipped with EDISIM, Instream, and HIPAA Validator Desktop.

Additionally, these TIBCO Foresight products support general XML schema and

flat-file definitions, although they do not currently ship with organization schemas

(e.g., MISMO). Please see XML Standards on page 13 and Flat-File Standards on

page 13 for more information.


Pre-X12 Standards

Version Shipped with

EDISIM?

Shipped with

Instream/HIPAA Validator

Desktop?

AIR-24, 25, 26, 27 Yes No

FREIG-26, 27 Yes No

MOTOR-23, 24, 25, 26, 27, 28 Yes No

OCEAN-24, 25, 26, 27, 29 Yes No

RAIL-23, 24, 25, 26, 27, 28 Yes No

TARIF-27 Yes No

UCS-23, 24, 25, 26, 30, 31, 32, 33 Yes No

X12 Standards


EDISIM?

Shipped with


Desktop?

2000 Yes No

2001 Yes No

2002 Yes No

2003 Yes No

2040 Yes No

3010 Yes No

3020 Yes No

3030, 3031, 3032 Yes No

3040, 3041, 3042 Yes No

3050, 3051, 3052 Yes No

3060, 3061, 3062 Yes No

3070, 3071, 3072 Yes No

4010, 4011, 4012 Yes 4010 only

4020, 4021, 4022 Yes No

4030, 4031, 4032 Yes No

4040, 4041, 4042 Yes No



EDISIM?

Shipped with


Desktop?

4050, 4051, 4052 Yes 4050 only

4060, 4061, 4062 Yes No

5010, 5011, 5012 Yes 5010 only

5020, 5021, 5022 Yes No

5030, 5031, 5032 Yes No

5040, 5041, 5042 Yes 5040 only (Instream only)

5050, 5051, 5052 Yes 5050 only

6010, 6011, 6012 Yes Yes

6020, 6021, 6022 Yes Yes

6030, 6031, 6032 Yes Yes

6040, 6041, 6042 Yes Yes

6050, 6051, 6052 Yes Yes

7010, 7011, 7012 Yes No

7020, 7021, 7022 Yes No

7030, 7031, 7032, Yes No

7040, 7041, 7042 Yes No

7050, 7051, 7052 Yes No

7060 Yes No


X12 Derivatives


EDISIM?

Shipped with


Desktop?

HIPAA Original, Addenda (Level 1, 2) Yes Yes

HIPAA Levels 3-7 No

(see note 1)

Yes

UCS: 3030, 3040, 3050, 3060, 3070, 4010,

4020, 4030, 4040, 4050, 5010

Yes No

VICS: 2003, 3010, 3020, 3030, 3040, 3050,

3060, 3070, 4010, 4020, 4030, 4040, 4050,

5010

Yes No

Note 1

The HIPAA Level 3 through 7 guidelines are encrypted within Instream and HIPAA Validator Desktop.

EDISIM will allow the creation of guidelines with additional rules that can be merged with these encrypted

guidelines, but EDISIM does not allow the encrypted HIPAA guidelines to be viewed, printed, or edited.

Medical Standards


EDISIM?

Shipped with


Desktop?

Healthcare Distribution Management

Association (HDMA) 856 Advance Ship

Notice (HDMA-4010856.std)

* Editor, Validator

only

Yes

HL7 2.3, 2.3.1, 2.4, 2.5.1, 2.6 Editor, Reference,

Validator only.

Yes

Medicaid pharmacy subrogation, NCPDP

Telecom D.0/Batch 1.2

* Editor, Validator

only

Yes

NCPDP Telecom 5.1/Batch 1.1 * Editor, Validator

only

Yes

NCPDP Telecom D.0/Batch 1.2 * Editor, Validator

only

Yes

NCPDP Post-Adjudication 4.2**

(NCPDP_PAH42.sef and

NCPDP_PAU42.sef)

* Editor, Validator

only

Yes



EDISIM?

Shipped with


Desktop?

NSF 3.1 * Editor, Validator

only

Yes

UB-92 6.0 * Editor, Validator

only

Yes

* does not ship with EDISIM. Contact TIBCO Foresight support.

** To use this guideline a minimum of Instream 8.4.0 Hotfix 4 and EDISIM 6.14.0 Hotfix 3 are required.

EDIFACT Standards


EDISIM?

Shipped with


Desktop?

UN1ICS Yes Instream only

UN4ICS Yes No



UN-901, 901v4, 902, 902v4 Yes No

UN-911, 911v4, 912, 912v4 Yes No

UN-921, 921v4 Yes No

UNCTRL Yes No

D93A, D93Av4 Yes D93A only (Instream only)

S93A, S93Av4 Yes No

D94A, D94Av4, D94B, D94Bv4 Yes No


D96A, D96Av4, D96B, D96Bv4 Yes D96A only (Instream only)





D01A, D01Av4, D01B, D01Bv4, D01C,

D01Cv4

Yes No




EDISIM?

Shipped with


Desktop?









D11A, D11AV4 D11B*, D11BV4* Yes No

D12A*, D12AV4*, D12B*, D12BV4* Yes No

D13A*, D13AV4, D13B*, D13BV4* Yes No

D14A, D14AV4*, D14B*, D14BV4* Yes No

D15AC, D15AV4*, D15B*, D15BV4* Yes No

D16A*, D16AV4*, D16B*, D16BV4* Yes No

D17A*, D17AV4* D17B*, D17BV4* Yes No

D18A*, D18AV4, D18B*, and D18BV4* Yes No

D19A*, D19AV4* Yes No

* These standards contain 5-digit sequence numbers. Install EDISIM 6.18.0 or later before using these standards.


EDIFACT Derivatives


EDISIM?

Shipped with Instream/HIPAA

Validator Desktop?

EANCOM93 Yes No

EAN97 (Version 3 and 4) Yes No

EAN02 (Syntax 3 and 4) Yes No

Other Standards


EDISIM?

Shipped with Instream/HIPAA

Validator Desktop?

ACH (ACH_CCDp and ACD_CTX) All except TDG,

Comparator, and

Analyzer

No

GENCOD 5 All except TDG No

ODETTE 94 All except TDG No

TRADACOMS Version 9 – 93 All except TDG Yes

XML Standards

EDISIM Standards Editor lets you import and customize XML schemas and DTDs.

It can then be saved as a standard and used in EDISIM Validator and

Instream/HIPAA Validator Desktop to validate XML data and to create HTML

reports of validation results. EDISIM TDG does not support XML schemas.

Flat-File Standards

EDISIM Standards Editor lets you create both fixed-length and delimited flat file

‘guidelines’, along with custom enveloping. You can use these flat-file guidelines in

EDISIM Validator and Instream/HIPAA Validator Desktop to validate flat-file

data, and to create HTML reports of validation results. EDISIM TDG and

Comparator do not support flat-file guidelines.

Standards and Guidelines Reference Manual Guideline Overview 15

Guideline Overview

Overview

Industry Guidelines

Industry guidelines (also referred to as Published guidelines) further define rules for

specific industries. For example, HIPAA guidelines have been developed based on

X12 standards related to healthcare.

Examples of other types of industry guidelines are those related to pharmacies and

transportation.

Customized Guidelines

Customized guidelines are those you develop using a published standard or guideline

as a starting point. They further define rules in places where the standard or industry

guideline is not specific enough or you need specialized behavior to use the

guideline with other Foresight products such as Dataswapper or Transaction

Insight®.

For example, you may want to mark certain optional fields as “not used, add internal

notes, etc. Customized guidelines are also referred to as companion guidelines.

Standard HIPAA Guidelines Developed

Health Care Claim Status Response (277-X212)

Health Care Claim Status Response Unsolicited (277U-X212)

Health Care Claim Acknowledgement (277CA-X214)

277 Healthcare

Information

Status

Notification


Life Cycle of a Guideline

Creating a Customized Guideline

Customized guidelines start life in EDISIM Standards Editor. Taking a published

guideline, you can modify the usage, codes, values, and other characteristics to

define exactly how the data should be. TIB_fsp_edisim_<n.n>_fseditor.pdf and

BusinessRules.pdf explain how to do this.

In this document, we base our customized guideline Our837P on 837-X222, a

Foresight-supplied 5010 837P with HIPAA types 1 and 2 rules already built in. How

did we know which guideline to use as a base? We looked it up in Supported

Guidelines on page 29.

We make changes to codes, values, usage, notes, etc., based on instructions in

TIB_fsp_edisim_<n.n>_fseditor.pdf. After saving, Our837P will have types 1, 2,

and 8 (our specifications are considered type 8).

Using a Customized Guideline with EDISIM

Once defined in Standards Editor, the guideline is actually a .STD file in EDISIM’s

User Files\Public Guidelines directory:

From there, it is available to all other EDISIM modules:

Comparator, when in migration mode, can also modify the guideline or create a new

one.

Export to SEF OUR837P

EDISIM Doc

Builder

Test Data

Generator

Analyzer Foresight

Validators

Standards

Reference

Comparator


Using a Merged Guideline

Merging Guidelines

Since EDISIM can only handle HIPAA types 1, 2, and 8, we have to merge in types

3-7. These are in special HIPAA guidelines that ship with HIPAA Validator

Desktop, Instream, Transaction Insight, Community Manager®, and other HIPAA-

specific products.

We use GuideMerge for this.

GuideMerge ships in the Bin directory of EDISIM and Instream®.

We will merge Our837P with the corresponding types 1-7 guideline, which we look

up in Supported Guidelines on page 29. This gives us a guideline with all HIPAA

rules plus our own rules from Our837P. We call it P_Our837P:

Our837P + PDSA5010837P = P_Our837P

This follows the custom of putting a P in front of the EDISIM guideline to identify

it as the “production” guideline - the one to be used with the HIPAA products.

GuideMerge.pdf gives all the details. Let’s assume that we are doing the merge

from a machine that is running Instream. Here’s what we would do:

1. Copy Our837P from EDISIM’s User Files\Public Guideline directory to

somewhere on the Instream machine.

2. Run GuideMerge to create P_Our837P.std.

Using Merged Guidelines with Instream

Copy the resulting P_Our837P to Instream’s Database directory.

If you have made other changes associated with the guideline, such as changes to the

validation profile (APF), the customer error message file, external tables or

databases, the $dir.ini, etc., include these in Instream too.

We now have guidelines and associated files in these places:


Using Merged Guidelines with TIBCO Foresight® Translator.

Copy the resulting P_Our837P to Foresight® Translator’s Database directory.

Foresight Translator does not need the APF, customer errors file, etc.

Using Merged Guidelines with Transaction Insight®

The web portal machine must have an installation of Instream with the same

guidelines and related files that were used for validation.

After initial validation, the detail results file is imported into Transaction Insight. A

Transaction Insight user corrects the data and it is sent to Instream to revalidate.

Typically, the two instances of Instream are not on the same server.

P_Our837P.std

(Types 1-8)

EDISIM Machine Instream

Our837P.std

(Types 1, 2, 8)

APF

CustomerFSBRErrs.txt

tables

databases

APF


tables

databases

Instream

Validation

(P_Our837P,

APF, errors file,

etc.)

DTL file EDI

Transaction

Insight

Instream

Revalidation

(P_Our837P,

APF, errors file,

etc.)

P_Our837P.std

(Types 1-8)

Our837P.std

(Types 1, 2, 8)

APF


tables

databases

EDISIM

EDISIM Foresight Translator


A more complete overview of a typical process like this might be:

DTL file EDI Instream

validation Response

Generator

999,

etc.

Docsplitter

Good Translator

Bad Transaction

Insight

Standards and Guidelines Reference Manual Anatomy of a Guideline 21

Anatomy of a Guideline

Overview

The following pages show an annotated example guideline document. Unused

segments were not printed in this example.


C

A

D

E

B

Sample Segment Table


See next page for explanations ->


Explanation for Segment Table Example

Page header. By default, there is no page header. You can insert one in EDISIM Doc Builder

under Profile | Options | Formatting tab.

Transaction or message title. You can change this in Standards Editor. Click on the

Transaction or message line at the top and change the Description in the top pane or in the

bottom pane’s Detail tab.

Functional group (X12 only). Normally, this should not be changed. If necessary, you can

change it in Standards Editor. Click on the transaction or message at the top, and then change

the Functional Group field in the bottom pane’s Detail tab.

Transaction or message purpose. You can change it in Standards Editor. Click on the

transaction or message at the top, and then change the Purpose field in the bottom pane’s

Detail tab.

Level notes. The top one is a level 1 note. The next one is a level 2 note. In this example, the

names of the note levels have been changed in Standards Editor. Use File | Properties | Level

Notes tab. Slowly click on the Note Name in the bottom of the dialog box and type the name.

To insert or change notes on the first page of the guideline document, click on the transaction

or message, click Edit Notes in the bottom pane’s Detail tab, select the level, and then type the

note.

Segment position number, showing position of the segment within the transaction or

message. You can change this position number in Standards Editor. Click on the transaction or

message at the top, and then change the Position Number field in the bottom pane’s Detail tab.

Be sure the new number is between the numbers of the surrounding segments, whether they are

used or not used.

Segment ID or tag. You cannot change it directly. Instead, use Standards Editor to create a

new segment in the segment dictionary and then insert it in this position in the transaction or

message.

Segment name or description. You can change this in EDISIM Standards Editor. To change

it in a particular location, click on the segment in the transaction set or message, and then

change the Description field in the bottom pane’s Detail tab. To change it throughout the

guideline, click on Dictionary Segments, to the same in the Segment dictionary under Dictionary

Objects at the top.

Segment requirement designator or status. This shows the requirement according to the

published standard on which your guideline is based. Normally, this should not be changed. If

necessary, you can change it in EDISIM Standards Editor. Click on the segment in the top

pane, and then change the Requirement Designator field in the bottom pane’s Detail tab.

B

C

D

E

F

G

H

I

A


Segment maximum use. You can change this in EDISIM Standards Editor. Click on the

segment in the top pane, and then change the Repeat Count field in the bottom pane’s Detail

tab.

Loop/group repeat count. You can change this in EDISIM Standards Editor. Click on the

Loop header in the top pane, and then change the Repeat Count field in the bottom pane’s

Detail tab.

Transaction or message notes and comments from the original standard. You cannot see or

change them in EDISIM Standards Editor. If you need to change them, use EDISIM Doc

Builder to export your guideline into a RTF file and open it in a word processor.

Notes start with “n” and are explained in the Transaction Set Notes section that appears after

the summary table.

Comments start with “c” and are explained in the Transaction Set Comments section that

appears after the summary table.

User requirement according to your own guideline. You can change this in EDISIM Standards

Editor. Click on the segment in the top pane, and then change the User Attributes field in the


Default footer. It includes the guideline’s name. It also includes the parent standard, page

number, and date that the document was generated in EDISIM Doc Builder. You can change

these in Document Builder. Open the guideline and choose Profile | Options | Formatting

tab.

K

L

M

N

J


Sample Segment Detail Page

O

P

Q

R

S T U

R

V

W X

See next page for explanations ->


Explanation for Segment Detail Page Example

Level (Heading, Detail, etc.) in which the segment appears.

Segment purpose. You can change this in EDISIM Standards Editor. Click on the segment in

the top pane, and then change the Purpose field in the bottom pane’s Detail tab. To change it

throughout the transaction, make the change in the Segments dictionary.

Syntax Notes, Semantic Notes, and Comments. You can change this in EDISIM Standards

Editor. Click on the segment in the segment dictionary and then make the changes in the


Level 1, 2, and 3 notes on segments, elements, or code values. You can change this in

EDISIM Standards Editor. Click on the segment or element and choose Edit Notes in the

bottom pane’s Detail tab. For a code, double-click on the code.

User requirement. Requirement according to your guideline. EDISIM Doc Builder options

(Profile | Options | Text Options) let you change how this appears (>>, "Must Use,"

"M/U," etc.). You can change the attribute in EDISIM Standards Editor. Click on the segment

or element in the top pane, and then change the User Attributes field in the bottom pane’s

Detail tab.

Element Name or Description. You can change this in EDISIM Standards Editor. Click on the

element and use the Description field in the bottom pane’s Detail tab. You can also change it in

the segment, composite, or element dictionaries if you want the change to be throughout the

guideline.

Attributes or representation. You can change this in EDISIM Standards Editor. Click on the

element and use the bottom pane’s Detail tab. The information includes:

Requirement. If you have selected Single Attribute Column under EDISIM Doc Builder’s

Profile Element Items tab, this is the effective requirement. Otherwise, it is the requirement

according to the underlying standard. You can change the effective requirement by

changing the user attributes in EDISIM Standards Editor. Click on the element and use the

Requirement Designator field in the bottom pane.

Repeat count. Change in EDISIM Standards Editor. Click on the element and use the

Repeat Count field in the bottom pane’s Detail tab.

Data type. Change in EDISIM Standards Editor. Click on the element in the Element

dictionary and use the Type field in the bottom pane’s Detail tab. See also DataTypes.pdf

in EDISIM’s Documentation directory. This is a global change.

Minimum length and maximum length. Change in EDISIM Standards Editor. Click on

the element and use the Minimum and Maximum fields in the bottom pane’s Detail tab.

P

R

S

T

U

O

Q


Element Purpose. You can change in EDISIM Standards Editor. Click on the element and use

the Purpose field in the bottom pane’s Detail tab.

Code value. BT is the only code value that is valid here, according to this guideline. Code

values only appear here if you have changed the original list from the originating standard. You

can change this list in EDISIM Standards Editor. Click on the element in the top pane and use

the Code Values tab at the bottom. You can also work with codes in the element, composite, or

segment dictionary. To change a code’s description, purpose, minimum, maximum, or type, use

the Element dictionary.

Code value definition and explanation (if any). You can change this list in EDISIM

Standards Editor. Click on the element in the top pane and use the Code Values tab at the

bottom. You can also work with codes in the element, composite, or segment dictionary.

V

W

X

Standards and Guidelines Reference Manual Supported Guidelines 29

Supported Guidelines

Important Information about Standard and Healthcare Guidelines for TIBCO Foresight® Instream® Users

Instream is available in two versions: Instream Standard Edition and Instream

Healthcare Edition.

Healthcare-related guidelines are shipped with both Instream Standard Edition and

Instream Healthcare Edition; however the following usage restrictions apply:

For customers who have licensed Instream Healthcare Edition, you may use the

healthcare guidelines included in Instream Healthcare Edition.

For customers who have licensed Instream Standard Edition, you may not use

any of the healthcare guidelines included in Instream Healthcare Edition.

Overview

TIBCO Foresight guidelines

Guidelines that ship with EDISIM, Instream, and HIPAA

Validator Desktop.

HIPAA

For those using TIBCO Foresight HIPAA validation products,

these guidelines in EDISIM contain types 1 and 2 edits.

HIPAA-based TIBCO Foresight guidelines in Validator

include these same EDISIM guidelines plus additional

guidelines with types 1-6 edits.

User guidelines Guidelines that you create in EDISIM Standards Editor. They

contain your company's edits.


Production guidelines Guidelines for Instream and HIPAA Validator Desktop that

you create by merging a user guideline with a TIBCO Foresight

guideline. HIPAA-based Production guidelines contain type 1-

7 edits.


HIPAA Guidelines

This document lists guidelines provided with the following TIBCO Foresight products: EDISIM, HIPAA Validator Desktop, and TIBCO

Foresight Instream. They include X12-4010, X12-4050, X12-5010 Errata, Public Companion Guides, and other Healthcare related guidelines.

Notes

1. X12-4010 —supported, however changes are no longer being incorporated into these guidelines.

2. X12-5010 before June 2010 Errata —supported, however these guidelines are no longer shipped with TIBCO Foresight products.


Table 1 - X12-4010

Version X12-4010

Document Name

EDISIM

Non-Addenda

Types 1-2

EDISIM

Addenda

No SVALU

Records

Types 1-2

HIPAA

Validator

Desktop or

Instream

Non-Addenda

Types 1-7

HIPAA Validator

Desktop or

Instream

Addenda

No SVALU Recs

Types 1-7

GuidelinePlus

Instream only

Addenda

SVALU Recs

Types 1-7 (PDSA)/

Types 1-2 (PDSX)

PDF

(www.wpc-

edi.com)

Value in GS08

(A1 at end =

Addenda)

Notes

270 Eligibility, Coverage or

Benefit Inquiry

270-A120 270AA120 4010270 B41A270

PDSA270

PDSX270

X092.pdf 004010X092

004010X092A1


Benefit Information

271-A120 271AA120 4010271 B41A271

PDSA271

PDSX271

X092.pdf 004010X092

004010X092A1

276 Health Care Claim Status

Request

276-A120 276AA120 4010276

B41A276 PDSA276

PDSX276

X093.pdf 004010X093

004010X093A1


Notification

277-A120 277AA120 4010277 B41A277

PDSA277

PDSX277

X093.pdf 004010X093

004010X093A1


Notification - unsolicited

277U-AA120 n/a

PDSX277U

004010

004010X093

004010X093A1

278 Health Care Services

Review Information –

Request for Review

278-A120 278AREQ 41-278RQ 41A278RQ

PDA278RQ

PDX278RQ

X094.pdf 004010X094

004010X094A1

BHT02=13


Review Information –

Response to Request for

Review

278-A320 278ARES 41-278RP 41A278RP

PDA278RP

PDX278RP

X094.pdf 004010X094

004010X094A1

BHT02=11

820 Payment Order /

Remittance Advice

820-A120 820AA120 4010-820 B41A820

PDSA820

PDSX820

X061.pdf 004010X061

004010X061A1


Version X12-4010

Document Name

EDISIM

Non-Addenda

Types 1-2

EDISIM

Addenda

No SVALU

Records

Types 1-2

HIPAA

Validator

Desktop or

Instream

Non-Addenda

Types 1-7

HIPAA Validator

Desktop or

Instream

Addenda

No SVALU Recs

Types 1-7

GuidelinePlus

Instream only

Addenda

SVALU Recs

Types 1-7 (PDSA)/

Types 1-2 (PDSX)

PDF

(www.wpc-

edi.com)

Value in GS08

(A1 at end =

Addenda)

Notes

834 Benefit Enrollment and

Maintenance

834-A120 834AA120 4010834 B41A834

PDSA834

PDSX834

X095.pdf 004010X095

004010X095A1

835 Health Care Claim

Payment/Advice

835-W120 835AW120 4010-835 B41A835

PDSA835

PDSX835

X091.pdf 004010X091

004010X091A1

837 Health Care Claim:

Professional

837-Q120 837AQ120 4010837P B41A837P (*CCI) PDSA837P (*CCI)

PDSX837P

X098.pdf 004010X098

004010X098A1

Uses SV1

segment

837 Health Care Claim: Dental 837-Q220 837AQ220 4010837D B41A837D

PDSA837D

PDSX837D

X097.pdf 004010X097

004010X097A1

Uses SV3

segment

837 Health Care Claim:

Institutional

837-Q320 837AQ320 4010837I B41A837I

PDSA837I

PDSX837I

X096.pdf 004010X096

004010X096A1

Uses SV2

segment

997 Functional

Acknowledgement

n/a n/a n/a n/a PDSA997

4010-997

Generic X12-4010 997 (no HIPAA rules),

although PDSA997 does generate structure

records in Instream DTL file.


Table 2 - X12-4050

Version X12-4050

Document Name

EDISIM Non-Addenda

Types 1-2

HIPAA Validator Desktop or Instream Addenda No SVALU Records

Types 1-7

GuidelinePlus Instream only Addenda SVALU Records

Types 1-7 /

Types 1-2

PDF (www.wpc-edi.com)

Value in GS08

Notes

275 Additional Information

to Support a Health

Care Claim or

Encounter

275-X151 4050-275 n/a 275-X151.pdf 004050X151


Request for Additional

Information

277-X150 4050-277 n/a 277-X150.pdf 004050X151


Table 3 - X12-5010 June 2010 Errata X12-5010 June 2010 Errata

Document Name

EDISIM **

Types 1-2

HIPAA Validator

Desktop or Instream

*

Types 1-2

HIPAA Validator Desktop or Instream

No SVALU Records

Types 1-7

GuidelinePlus

Instream only

DS, RG, TI Types 1-7 Types 1-2

PDF

(www.wpc-edi.com)

Value in GS08

Notes


Benefit Inquiry

270-X279 270-X279 5010-270X279 PDSA5010270X279

PDSX5010270X279

x203_270_271.pdf 005010X279A1


Benefit Information

271-X279 271-X279 5010-271X279 PDSA5010271X279

PDSX5010271X279

x203_270_271.pdf 005010X279A1


Status Request

276-X212 276-X212 5010-276X212 PDSA5010276X212

PDSX5010276X212

276-X212-5010.pdf 005010X212


Status Request –

Medicare

n/a 5010-MEDICARE-

276X212

PDSA5010MEDICARE-

276X212

none 005010X212


Status Response

277-X212 277-X212 5010-277X212 PDSA5010277X212

PDSX5010277X212

277-X212-5010.pdf 005010X212


Status Response –

Unsolicited

277U-X212 277U-X212 n/a n/a

PDSX5010-277UX212

005010

005010X212


Acknowledgement

277CA-X214 277CA-X214 5010-277CAX214 PDSA5010277CAX214

PDSX5010277CAX214

X214_277CA.pdf 005010X214


Status Response-

Medicare

n/a 5010-MEDICARE-

277X212

PDSA5010MEDICARE-

277X212.std

none 005010X212


Request for Review

278X217Q 278X217Q 5010-278X217Q PDSA5010278X217Q

PDSX5010278X217Q

278X217Q-

5010.pdf

005010X217 BHT02=01,

13, or 36


X12-5010 June 2010 Errata

Document Name

EDISIM **

Types 1-2

HIPAA Validator

Desktop or Instream

*

Types 1-2


No SVALU Records

Types 1-7

GuidelinePlus

Instream only


PDF

(www.wpc-edi.com)

Value in GS08

Notes


Response to Review

278X217R 278X217R 5010-278X217R PDSA5010278X217R

PDSX5010278X217R

278X217R-5010.pdf 005010X217 BHT02=11

820 Payroll Deducted and

Other Group Premium

Payment for

Insurance Products

820-X218 820-X218 5010-820 PDSA5010820

PDSX5010820

820-x218-5010.pdf 005010X218

824 Application Advice 824-X166

824-X186A1

824-X166

824-X186A1

n/a n/a 824-x166-5010.pdf

824-x186A1-

5010.pdf

005010X166

005010X186A1

834 Benefit Enrollment

and Maintenance

834-X220 834-X220 5010-834 PDSA5010834

PDSX5010834

834-x220-5010.pdf

005010X220A1


Payment/Advice

835-X221 835-X221 5010-835 PDSA5010835

PDSX5010835

835-X221-5010.pdf 005010X221A1

837D Health Care Claims

Dental

837-X224 837-X224 5010837D PDSA5010837D

PDSX5010837D

837-x224-5010.pdf 005010X224A2

Uses SV1

segment

837I Health Care Claim

Institutional

837-X223 837-X223 5010837I PDSA5010837I

PDSX5010837I

837-x223-5010.pdf 005010X223A2

Uses SV3

segment

837I Health Care Claim

Institutional –

Medicare A

n/a n/a 5010-

MEDICAREA

PDSA5010MEDICAREA none 005010X223A2 Uses SV2

segment

837P Health Care Claim

Professional

837-X222 837-X222 5010837P (*CCI) PDSA5010837P (*CCI)

PDSX5010837P

837-x222-5010.pdf 005010X222A1


X12-5010 June 2010 Errata

Document Name

EDISIM **

Types 1-2

HIPAA Validator

Desktop or Instream

*

Types 1-2


No SVALU Records

Types 1-7

GuidelinePlus

Instream only


PDF

(www.wpc-edi.com)

Value in GS08

Notes

837P Health Care Claim

Professional –

Medicare B

n/a n/a 5010-

MEDICAREB

(*CCI)

PDSA5010MEDICAREB

(*CCI)

none 005010X222A1

Healthcare Guidelines Non-HIPAA Mandated

Document Name

EDISIM **

Types 1-2

HIPAA Validator

Desktop or Instream

*Types 1-2


No SVALU Records

Types 1-7

GuidelinePlus

Instream only



Value in GS08

275 Health Care Claim or

Encounter

275-X314 275-X314 6020-275X314 PDSA6020-275X314

PDSX6020-275X314

275-X314-6020.pdf 006020X314


Review

275-X316 275-X316 6020-275X316 PDSA6020-275X316

PDSX6020-275X316

275-X316-6020.pdf 006020X316


Pending Status

Information

277-X228 277-X228 n/a PDSX5010-277X228

277-X228-5010.pdf 005010X228



Information (277)

277-X213 277-X213 n/a PDSX5010-277X213 277-X213-5010.pdf 005010X213


Document Name

EDISIM **

Types 1-2

HIPAA Validator

Desktop or Instream

*Types 1-2


No SVALU Records

Types 1-7

GuidelinePlus

Instream only



Value in GS08



Information

277-X313 277-X313 6020-277X313 PDSA6020-277X313

PDSX6020-277X313

277-X313-6020.pdf 006020X313

277 Data Reporting

Acknowledgment

277-X364 277-X364 5010-277DRAX364 PDSA5010277DRAX364 277-X364-5010.pdf 005010X364


Review Information -

Inquiry

278X215I 278X215I 5010-278X215I PDSA5010-278X215I

PDSX5010-278X215I

278-X215I-5010.pdf 005010X215



Response

278X215R 278X215R 5010-278X215R PDSA5010-278X215R

PDSX5010-278X215R

278-X215R-5010.pdf 005010X215



Acknowledgement

278X216A 278X216A 5010-278X216A PDSA5010-278X216A

PDSX5010-278X216A

278-X216A-5010.pdf 005010X216



Notification

278X216N 278X216N 5010-278X216N PDSA5010-278X216N

PDSX5010-278X216N

278-X216N-5010.pdf 005010X216

820 Health Insurance

Exchange: Related

Payment

820-X306 820-X306 5010-820X306 PDSA5010-820X306

PDSX5010-820X306

820-x306-5010.pdf 005010X306


Exchange: Related

Payment (CMS

Companion Guideline)

n/a 820-X306 5010-HIX-820X306 PDSA5010HIX-820X306 No PDF 005010X306

834 Benefit Enrollment And

Maintenance: Health Care

Exchange (CMS

n/a 834-X220 5010-HIX-834X22 PDSA5010HIX-834X220 No PDF

005010X220A1


Document Name

EDISIM **

Types 1-2

HIPAA Validator

Desktop or Instream

*Types 1-2


No SVALU Records

Types 1-7

GuidelinePlus

Instream only



Value in GS08

Companion Guideline)


Exchange: Enrollment

834-X307 834-X307 5010-834X307 PDSA5010-834X307

PDSX5010-834X307

834-x307-5010.pdf 005010X307

834 Plan Member Reporting 834-X318 834-X318 5010-834X318 PDSA5010-834X318

PDSX5010-834X318

834-x318-5010.pdf 005010X318

837D Dental, Post-Adjudication

Claims Data Reporting

837-X300 837-X300 5010-837X300 PDSA5010-837X300

PDSX5010-837X300

837-x300-5010.pdf 005010X300

837I Institutional, Post-

Adjudication Claims Data

Reporting

837-X299 837-X299 5010-837X299 PDSA5010-837X299

PDSX5010-837X299

837-x299-5010.pdf 005010X299

837P Professional, Post-

Adjudication Claims Data

Reporting

837-X298 837-X298 5010-837X298 PDSA5010-837X298

PDSX5010-837X298

837-x298-5010.pdf 005010X298

997 Functional

Acknowledgment

5010-997 5010-997 n/a n/a

PDSX5010997

No PDF

005010

999 Implementation

Acknowledgment

999-X231 999-X231 5010-999X231 PDSA5010-999X231

PDSX5010-999X231

999_X231.pdf 005010

005010X231


Healthcare Guidelines for TIBCO Foresight® Community Manager®

Guideline Name Purpose Notes

FSSD5010-270X279

FSSD5010-271X279

FSSD5010-276X212

FSSD5010-277X212

FSSD5010-278X217REQ

FSSD5010-278X217RES

FSSD5010-820X218

FSSD5010-834X220

FSSD5010-835X221

FSSD5010-837DX224

FSSD5010-837IX223

FSSD5010-837PX222

FSSD5010-MEDICAREA

FSSD5010-MEDICAREB

Community Manager® only

For customers who host their own Community Manager, merge these with your

company guidelines to create production guidelines that contain scenarios.

Guidelines are installed in Instream’s

CommunityManagerGuidelines directory.


General Guidelines

Document Name Purpose GuidelinePlus

SVALU Records

GS01

210 Motor Carrier Freight Details and Invoice

TIBCO Foresight Transaction Insight

Standard Edition

PDSAGM5010-210 IM

810 Invoice PDSAGM5010-810 IN

820 Payment Order/Remittance Advice PDSAGM5010-820 RA

850 Purchase Order PDSAGM5010-850 PO

855 Purchase Order Acknowledgment PDSAGM5010-855 PR

856 Ship Notice/Manifest PDSAGM5010-856 SH

860 Purchase Order Change Request – Buyer Initiated PDSAGM5010-860 PC

Standards and Guidelines Reference Manual Appendix A: HL7 Standards 43

Appendix A: HL7 Standards

Overview

This section describes how to use HL7 transactions, also known as “messages”, in

TIBCO Foresight products.

Health Level Seven International (HL7) has data interchange standards for health

information transactions. HL7 Version 2 Messaging Standards versions as listed below

are supported by TIBCO Foresight validation products.

HL7 in TIBCO Foresight Products

The HL7 guidelines

2.3

2.3.1

2.4

2.5.1

2.6

are distributed with these TIBCO Foresight products:

HIPAA Validator Desktop version 8.0.0 or later

Instream version 8.0.0 or later – validation only.

You can use them with these modules of EDISIM 6.10.1 or later (copy the appropriate

standard, for example HL7_26.std, from Instream’s or HIPAA Validator Desktop’s

Database folder to EDISIM’s User Files\Public Guidelines directory):

EDISIM Standards Editor – including the ability to create rules

EDISIM Standards Reference


HL7 does not work with EDISIM’s Doc Builder, Test Data Generator, Comparator,

Analyzer, or Library modules.

HL7 standards and guidelines can also be used with Foresight Translator version 3.0.0 or

later.

Sample Data and Instream Scripts

Instream HIPAA

Validator

Desktop

Filename Directory Notes

HL7_ORU_R01_Clean.txt DemoData HL7 ORU R01 file. Used

by Instream’s

V_ORUR01_HL7_Clean

script.

V_ORUR01_HL7_Clean Scripts Validates

HL7_ORU_R01_Clean.txt,

an HL7 file.


Big Picture

Messages

HL7 provides the following messages (referred to in the X12 community as transaction

types):

Patient Administration

Order Entry

Queries

Financial Management

Observation Reporting

Master Files

Medical Records/Information Management

Scheduling (View Brief)

Patient Referral

Patient Care

Clinical Laboratory Automation

Application Management

Personnel Management

Claims and Reimbursement

Materials Management

Parts of a Message

HL-7 messages:

Begin with a Start Message (MSH) segment, which contains information such as

from, to, date, time, etc.

Contain no End Message segment. The end of a message is signaled when another

Start Message (or Start Batch or Start File) segment is seen, or upon end-of-file.

One or more messages may be grouped into a Batch, which is explained below.

Start of message

Start of next message


Parts of a Batch

One or more messages may be grouped into a batch. A batch:

begins with a Start Batch Segment (BHS)

is followed by one or more messages

ends with an End Batch Segment (BTS).

One or more batches may be grouped into a file. A file:

begins with a Start File Segment (FHS)

ends with an End File Segment (FTS).

HL7 Specific Information

Users who are familiar with EDISIM, Instream, HIPAA Validator Desktop, and

Foresight Translator from working with X12 EDI will find the following differences

when working with the HL7 standard.

Terminology

General terminology differences between X12 data and HL7 data are as follows:

X12 HL7

Interchange File

Functional Group Batch

Transaction Set Message

Loop Segment Group

Segment Segment

Sub-Composite Members Field Sub-Components

Element Fields

Code Set Table


Requirements Coding

The following Requirements characters are used in the Requirements field in HL7

messages:

Character X12 Meaning HL7 Meaning

M Mandatory Required

O Optional Optional

C Conditional Conditional

X (none) Not Used

B (none) Backward

Compatibility

W (none) Withdrawn


Sub-Composites

Composites in HL7 transactions may contain sub-composites.

Codes

There will be a new Responsible Agency Code of ‘H’ in the fourth field if the .INI

record to identify HL7 standards.

Enveloping

Enveloping differences between X12 data and HL7 data are as follows:

The HL7

segment…

Defined as… Is like this segment in X12…

FSH File Header Segment

(includes delimiter overrides)

ISA (optional)

BSH Batch Header Segment


GS (optional)

MSH Message Header Segment


ST

(none) Message Trailer Segment SE

BST Batch Trailer Segment GE (optional, but required if BSH

is used)

FST File Trailer Segment IEA (optional, but required if FSH

is used)

HL7 Identifier in Validation Detail File

GEN record 17021 within the validation detail file indicates the data is HL7. The “1” in

front of the GEN record number is the line number in the data file.

Composite

Sub-composite


HL7 Data Types

The following data types are commonly found in HL7 transactions/messages. For

additional information, refer to the official HL7 documentation for Data Types

(http://www.hl7.org).

Data Type Description

AD Address

CCD Charge code and date

CCP Channel calibration parameters

CD Channel definiion

CE Coded ENTRY

CF Coded element with formatted values

CK Composite ID with check digit

CM Composite

CN Composite ID number and name

CNE Coded with no exceptions

CQ Composite quantity with units

CP Composite price

CWE Coded with exceptions

CX Extended Composite ID with check digit

DLN Driver’s license number

DR Date/time range

DT Data

ED Encapsulated data

EI Entity identifier

FC Financial class

FN Family name

FT Formatted text data

HD Hierarchic designator

ID Coded value for HL7-defined tables

IS Coded value for user-defined tables

JCC Job code/class

MA Multiplexed array

http://www.hl7.org/


Data Type Description

MO Money

NA Numeric array

NM Numeric

PL Person location

PN Person

PPN Performing person time stamp

SI Sequence ID

PT Processing type

QIP Query input parameter list

QSC Query selection criteria

RCD Row column definition

RI Repeat interval

RP Reference pointer

SAD Street address

SCV Scheduling class value pair

SN Structured numeric

SRT Sort order

ST String data

TM Time

TQ Timing quantity

TS Timestamp

TX Text data

VH Visiting hours

VID Version identifier

XAD Extended address

XCN Extended composite ID number and name for persons

XON Extended composite name and identification number for organizations

XPN Extended person name

XTN Extended telecommunications number

Standards and Guidelines Reference Manual Appendix B: NCPDP Standards 51

Appendix B: NCPDP Standards

Overview

This section describes how to use NCPDP transactions in TIBCO

Foresight products.

The National Council for Prescription Drug Programs (NCPDP) has data interchange

standards for pharmacy services. NCPDP's Telecommunication Standard Version 5.1

and D.0 are supported by TIBCO Foresight validation products (EDISIM, HIPAA

Validator Desktop, and Instream). The batch transaction standard for enveloping is

Version 1.1 for HIPAA.

NCPDP in TIBCO Foresight Products

The NCPDP5 and NCPDPD0 guidelines are HIPAA-specific and so are distributed

with the following TIBCO Foresight products:

HIPAA Validator Desktop version 4.1 or later

Instream version 4.1 or later – validation (including Trading Partner Automation)

only.

You can use it with these modules of EDISIM 5.13 or later (copy NCPDP5.STD and

NCPDPD0.STD from Instream’s or HIPAA Validator Desktop’s Database folder to

EDISIM’s User Files\Public Guidelines directory:

EDISIM Standards Editor – including the ability to create rules

EDISIM Document Builder – creates X12-format output

EDISIM Comparator

EDISIM Standards Reference

NCPDP does not work with EDISIM’s Test Data Generator and Analyzer modules.


Sample Data and Instream Scripts

Instream HIPAA

Validator

Desktop

Filename Directory Notes

NCPDP_BillRequest_51.txt DemoData A Billing (Request)

containing three G1

segments, each with one

claim.

NCPDP_ Response _51.txt DemoData A B2 Billing Reversal

(Response) containing five

G1 segments, each

containing segment 21, a

Response Status Segment.

V_NCPDP_51_BillRequest Scripts Validates

NCPDP_BillRequest_51.txt.

Terminology

X12 NCPDP

Interchange Batch

Functional Group none

Transaction Set Transmission

Loop none

Claim or other application

document

Transaction

Segment Segment

Composite none

Element Element

Code Set none


Big Picture

Transaction Sets

Billing

B1 – Billing

B2 – Billing Reversal

B3 – Billing Rebill

Controlled Substance Reporting

C1 – Controlled Substance Reporting

C2 – Controlled Substance Reversal

C3 – Controlled Substance Rebill

Eligibility

E1 – Eligibility Verification

Information Reporting

N1 – Information Reporting

N2 – Information Reversal

N3 – Information Rebill

Prior Authorization

P1 – Prior Authorization Request and Billing

P2 – Prior Authorization Reversal

P3 – Prior Authorization Inquiry

P4 – Prior Authorization Request Only

Request or Response

Each transaction can be either a:

Transaction The originating request.

Response Acknowledgement of a request. Responses are prefaced with the

letter R in EDISIM. For example, the response to a B1 is an RB1.


Parts of a Batch

A batch contains these parts:

One 00 Transmission header segment with ISA-type information.

One or more G1 detail records, each containing one to four “transactions” such as

claims.

One 99 trailer containing a control number and segment count.

Codes

NCPDP doesn’t have actual code sets but the standard specifies allowed values. These

are implemented as code sets in TIBCO Foresight products.

Elements

The first value in a segment is AM followed by the segment tag.

Other elements can be in any order, except mandatory elements come before

optional elements.

Each element in the transaction sections of the batch (in the claim itself, for

example) starts with the Field Separator character (x1C). Elements in header

segments have no delimiters.

Leading zeroes and leading or trailing spaces are tolerated.

Elements in transaction segments have maximum lengths but no minimum lengths.

Elements in header segments are fixed length.

Values have two parts: a two-character element tag, and then data.

Element IDs

NCPDP element IDs can be in these formats.

nnn Only in batch control segments. Example: 303

nnn-aa The usual NCPDP element ID. The last two characters are called the element tag.


Since EDISIM and Library only allow up to four digits for element IDs, they are

abbreviated by taking out the third digit and the hyphen. Example: 101-7R becomes

107R in EDISIM. The description will include the full ID:

Element Types

Type As shown in

EDISIM

Notes

Code Lists ID These re values specified in the sta, not code lists

managed by outside organizations, as in X12.

Alphanumeric AN Data is left justified with spaces padded on the right. All

letters are uppercase.

Numeric N or Nn n is the number of implied decimal places. Do not include

explicit decimals in data. The sign is over punched in the

last digit (see chart below).

Data is right justified and zero filled.

Signed Values

To avoid expanding the size of a field, plus or minus characters are combined with the

last digit of data. The overpunch character replaces the right-most character.

Positive Example

To determine the EDI data for $19.95, look up the last digit (5) in the Value column of

the chart below. Now move to the right one column to find the value that would

represent 5 and signed positive is E. Therefore, the positive value $19.95 appears as

199E in the data, assuming the data type is N2.

Negative Example

To calculate the EDI data for minus $19.95, look up the last digit (5) in the Value

column of the chart below. Now move to the right until you find the column for signed

negative graphic. The value that represents 5 and signed negative is N. Negative $19.95

appears as 199N in the data.


Value Signed Positive Graphic Signed Negative Graphic

0 { }

1 A J

2 B K

3 C L

4 D M

5 E N

6 F O

7 G P

8 H Q

9 I R

Repeating Elements

Elements that can repeat are preceded by a count element containing the number of

repeating elements to follow.

If the Coordination of Benefits/Other Payments Count has a value of 2, the next

four elements cycle twice:


Segments

The segment separator is always hex 1E

The first segment in a batch is always the 00 Header segment, which is fixed length

without delimiters. It serves the same function as X12’s ISA.

The GIT segment that you see in TIBCO Foresight products is for requests. It

contains the reference number from the G1 segment, plus the elements from the

Request Header Segment QT. GIT is a TIBCO Foresight structure and is not part

of the standard.

The GIR segment that you see in TIBCO Foresight products is for responses. It

contains the reference number from the G1 segment, plus the elements from the

Response Header Segment RT. GIR is a TIBCO Foresight structure and is not part

of the standard.

Enveloping

The first segment in a batch is always the Transmission Header Segment, which serves

the same purpose as the X12 ISA. It starts with hex 02 followed by the 00 segment

identifier. It has fixed-length, required fields with no delimiters, and ends with hex 03.

Example (element IDs shown below):

Detail Segments

The G1 record starts with hex 02 followed by the segment ID G1 and then fixed-length,

undelimited fields in the Request Header Segment or Response Header Segment. It ends

with a hex 03.

The G1 record contains the application segments. These always start with the Segment

Separator character hex 1E, followed by AM and then the segment ID.

Within a G1, segments after the 07 segment are in any order. Likewise, within a segment,

elements can be in any order as long as mandatory elements come before optional

elements.

One G1 record can contain up to four claims.


Trailer Segment

The trailer record starts with a hex 02 and ends with a hex 03. All elements are fixed

length with no delimiters. It contains a batch number that should match the one in the

00 record, and a count of all 00, G1, and 99 records in the batch.

Example Batch

The following example is a request batch with three G1 segments, each with one claim.


Sample batch with three G1s

Batches always start with a 00 Transaction Set Header record. The control number is in

bold.

The T is the transmission type and indicates that the batch contains transactions

(requests) rather than responses.

Start of the first G1 record. Notice the B1, indicating that these will be Billing

transactions.

Start of the next G1 record.

Start of the 99 record, the trailer record. The control number is in bold and matches the

one in the 00 record. The last value in the 99 record is a count. It is 5 here: one 00 record, three

G1 records, and one 99 record.

Anatomy of a G1

The GI tag is immediately followed by the fixed-length elements in the Request Header

Segment (QH in TIBCO Foresight products) or the Response Header Segment (RH in TIBCO

Foresight products). This is underlined in the example. Each segment ends with a segment

terminator hex 1E, which displays as a hyphen in this example.

The mandatory 04 segment is next. Like all detail segments, it is preceded with AM.

Trailing spaces are optional and are shown in this example. Each element, including each

segment tag, begins with a hex ‘1C’. These display as boxes in the example above.

The conditional 01 segment is omitted in this example. The 07 segment is next and

begins the claim. This claim includes the 11 and 03 segments.


Data with no 1.1 “Enveloping”

Validation requires the 1.1 enveloping around the 5.1 data. This includes everything up

to and including the 10-digit transaction reference number after G1, and the 99 segment

at the end. The 1.1 areas are bold in the example below.

If your data does not have 1.1 enveloping, you can validate if you add the contents of a

header file to the beginning of your data and the contents of the trailer file to the end.

You can find these files in the DemoData directory of Instream and HIPAA Validator

Desktop:

File (DemoData

directory)

Contents Use if your data is …

HeaderTrans.NCPDP Beginning of the NCPDP transmission

file that has no 1.1 “enveloping”

A transmission

HeaderResponse.NCPDP Beginning of the NCPDP response file

that has no 1.1 “enveloping”

A response

Trailer.NCPDP End of the EDI file that has no 1.1

“enveloping”

Either transmission or

response

The data can have only one transmission (or set), and cannot have extraneous characters

like end-of-files or padding after the last element.

To determine whether your data is a transmission or response, look at the first few

characters:

Transmission If the data starts with six characters followed by 51 or D0 (as in

01262851B1OKA01 …), then it is a transmission and you can put the

contents of HeaderTrans.NCPDP in front of it and Trailer.NCPDP

after it.

Response If the data starts with 51 or D0 (as in 51B1OKA01 …), then it is a

response and you can put the contents of HeaderResponse.NCPDP in

front of it and Trailer.NCPDP after it.

standards and guidelines reference manual

Documents