AHCCCS EDI

AHCCCS EDI Testing Procedures

AHCCCS EDI trading partners are responsible for ensuring that their transactions are compliant with HIPAA mandates based on the types of testing described below.

AHCCCS encourages providers and other entities to use either a third party tool or AHCCCS’ Community Manager tool to certify that the entity can produce and accept HIPAA compliant transactions. Success is determined by the ability to pass the seven types of compliance tests listed below. The initial four of the seven types of testing are also used as categories for edits performed by the AHCCCS translator.

Arizona Health Care Cost Containment System (AHCCCS) is Arizona’s Medicaid agency that offers health care programs to serve Arizona residents.

EDI Testing Requirements

The testing types have been developed by the Workgroup for Electronic Data Interchange (WEDI), a private sector organization concerned with implementation of electronic transactions. They are:

  1. Integrity Testing – This kind of testing validates the basic syntactical integrity of the provider’s EDI file.
  2. Implementation Guide – Requirements Testing – This kind of testing involves requirements imposed by the transaction’s HIPAA Implementation Guide, including validation of data element values specified in the Guide.
  3. Balancing Testing – Balancing verification requires that summary-level data be numerically consistent with corresponding detail level data, as defined in the transaction’s Implementation Guide.
  4. Inter-Segment Situation Testing – Situation testing validates inter-segment situations specified in the Implementation Guide (e.g., for accident claims, an Accident Date must present).
  5. External Code Set Testing – This kind of testing validates code set values for HIPAA mandated codes defined and maintained outside of Implementation Guides. HCPCS Procedure Codes and NDC Drug Codes are examples.
  6. Product Type or Line of Service Testing – This kind of testing validates specific requirements defined in the Implementation Guide for specialized services such as durable medical equipment (DME).
  7. Trading Partner-Specific Testing – Testing of trading partner requirements involves Implementation Guide requirements for transactions to or from Medicare, Medicaid and Indian Health Services. For AHCCCS trading partners, trading partner requirement testing includes testing of the approaches that AHCCCS has taken to accommodate necessary data within HIPAA compliant transactions and code sets.

To learn more about HIPAA EDI and become a certified  EDI Professional please visit our course schedule page.

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