|
DHP HIPAA Transactions Homepage
The objective of this section of our website is to provide you with information on Dean Health Plan's efforts to achieve compliance with the transaction component of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Administrative Simplification Regulations.
We provide information regarding:
- DHP Contingency Plan
- Transaction Companion Guides
- Steps for Getting Started with Electronic Data Interchange (EDI)
- Transaction Testing Process
- HIPAA Information Links
- Contact Us
- Glossary of Terms
DHP is prepared to process HIPAA compliant transactions. DHP has implemented a contingency plan in support of the Centers for Medicare and Medicaid Services' (CMS') recent clarification regarding electronic claims. CMS will work with trading partners to achieve HIPAA compliance by temporarily accepting electronic claims in the format used prior to 10/16/2003. DHP will also continue to accept transactions in their existing proprietary format from current submitters. DHP will monitor those partners' progress in achieving compliance, working with them to complete testing and implementation. Providers submitting electronic transactions for the first time post 10/16/2003 will be required to use HIPAA compliant formats.
If you have any questions, please contact the DHP EDI team at dhpedi@deancare.com.
DHP supports all HIPAA compliant electronic transactions.
Please click here for Dean Health Plan's Claim Adjustment Reason Codes. The Claim Adjustment Reason Codes will be updated quarterly. To ensure you are referencing the correct reason codes, please download this file on a quarterly basis and discard all earlier documents.
| Transaction | Transaction Number | Companion Guide |
|---|---|---|
| Health Care Claim Institutional and Professional | 837 |
Companion Guide
400 kb PDF |
| Health Care Payment/Advice | 835 |
Companion Guide
1.1 meg PDF |
| Health Care Eligibility/Benefit Inquiry and Response | 270/271 |
Companion Guide
1.2 meg PDF |
| Health Care Claim Status Request and Response | 276/277 |
Companion Guide
1.1 meg PDF |
| Health Care Services Review – Request for Review and Response | 278 |
Companion Guide
2.7 meg PDF |
| Benefit Enrollment and Maintenance | 834 |
Companion Guide
1.2 meg PDF |
| Payroll Deducted and Other Group Premium Payments | 820 |
Companion Guide
1.2 meg PDF |
PDF files require the free Adobe Acrobat Reader.
Download the Adobe
Acrobat Reader here.
Steps for Getting Started with Electronic Data Interchange (EDI)
Trading partners interested in submitting electronic transactions to DHP can download and complete an EDI set up form. Please complete the form and e-mail or fax to the DHP EDI team at dhpedi@deancare.com or (608) 836-6335. Trading partners can also call (866) 481-3421 to request an EDI set up form.
- EDI set up Form - PDF 55 kb PDF
- EDI set up Form - Word Doc 1.4 meg Word Doc
All trading partners will be required to sign a Trading Partner Agreement (TPA). Please click here to download the form. Please complete the form and mail two signed copies to the following address:
Dean Health Plan
Attention: EDI Department
1277 Deming Way
Madison, WI 53717
DHP will mail a signed copy of the TPA back to each trading partner.
The EDI team will set up trading partners with access to our File Transfer Protocol (FTP) server in order to start testing the transmittal process. Trading partners will be required to use FTP client software that will support 128 SSL Data encryption to exchange transactions with DHP. DHP has tested the FTP server using WS-FTP Pro. Please find a link to WS-FTP Pro website in the HIPAA Information Links.
DHP will test all trading partner transactions prior to moving into a production environment. Below, please find the steps DHP will take when testing a transaction.
- Create test folder on FTP server for trading partner
- Test trading partner files with Claredi ® to ensure that transactions are valid using the following testing categories.
- Integrity Testing - Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules. This will validate the basic syntactical integrity of the EDI submission.
- Requirement Testing - Testing of HIPAA implementation guide specific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes, elements and segments. Also included in this type is testing for HIPAA required or intra-segment situational data elements, testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12 code list or table.
- Balancing Testing - Testing the transaction for balanced field totals, financial balancing of claims or remittance advice, and balancing of summary fields, if appropriate. An example of this includes items such as all claim line item amounts equal the total claim amount.
- Situation Testing - The testing of specific inter-segment situations described in the HIPAA Implementation Guides, such that: If A occurs then B must be populated. This is considered to include the validation of situational fields given values or situations present elsewhere in the file. Example: if the claim is for an accident, the accident date must be present.
- Code Set Testing - Testing for valid Implementation Guide-specific code set values and other code sets adopted as HIPAA standards. This level of testing will not only validate the code sets but also make sure the usage is appropriate for any particular transaction and appropriate with the coding guidelines that apply to the specific code set. Validates external code sets and tables such as CPT , ICD-9 , CDT ,NDC , status codes, adjustment reason codes, and their appropriate use for the transaction.
- Product Types/Types of Service Testing - This testing
type is required to ensure that the segments/records of
data that differ based on certain healthcare services are
properly created and processed into claims data formats.
These specific requirements are described in the
Implementation Guides for the different product types
or lines of service. For example, ambulance, chiropractic,
podiatry, home health, parenteral and enteral nutrition,
durable medical equipment, psychiatry, and other specialized
services have specific requirements in the Implementation
Guide that must be tested before putting the transaction
in production. This type of testing only applies to a
trading partner candidate that conducts transactions for
the specific line of business or product type.1
- Work with trading partner to eliminate all Claredi ® identified errors
- Process transaction in test environment to ensure accurate results
- Set up production folder for trading partner on FTP Server.
Centers for Medicare and Medicaid Services
Workgroup for Electronic Data Interchange
Strategic National Implementation Process
Wisconsin Medicaid and BadgerCare Coding Updates
If you have any questions, please contact the DHP EDI team at dhpedi@deancare.com or (866) 481-3421.
- X12 - uniform standard for electronic exchange of business transactions developed by the Accredited Standards Committee
- NCPDP - National Council for Prescription Drug Programs
- CPT - Current Procedural Terminology
- ICD-9 - International Classification of Diseases - 9th Edition, Clinical Modification, Volume 3
- CDT - Current Dental Terminology
- NDC - National Drug Codes
1 WEDISNIP Transactions workgroup - Testing Sub-workgroup. "Transaction Compliance and Certification", 08/23/2002.
lead to an external site |