EDI Trading Partner Guides for electronic data interchange
EDI Trading Partner basic requirements and definitions are given in the blog due to the fact that Security Health Plan is unable to accept electronic transmissions of claims or other transactions set forth in the HIPAA Transactions/Code Sets regulations other than in the standardized format required by those regulations. If the affiliated provider (EDI Trading Partner) transmits the transactions electronically to Security Health Plan, he or she will need to transmit them in the standardized format or use a clearinghouse to do so. EDI Trading Partner guides set forth the terms governing the transmissions of such electronic transactions by Security Health Plan and affiliated providers who will be considered trading partners for purposes of these transactions.
Definitions
The following capitalized terms shall have the following meanings:
- “DHHS” means the Department of Health and Human Services or its designated representative.
- “Implementation guide” means the industry guide for a Standard Transaction adopted for use under HIPAA and setting forth required formats, data elements, code sets and all other implementation specifications.
- “Information” means electronic information transmitted, provided or otherwise exchanged between Security Health Plan and the affiliated provider.
- “Standard transaction” means an electronic transmission governed by the Transaction Rule.
- “Trading partner” means an entity that transmits information to or receives information from another entity electronically.
- “Transaction rule” means HIPAA’s transaction standard regulation as set forth at 42 CFR §§ 160 and 162 and as amended.
Documents: Standards and Guidelines
Security Health Plan and the affiliated provider may electronically transmit to or receive from each other any of the standard transactions (collectively “documents”). All documents shall be transmitted and processed in accordance with those standards and guidelines specified in the implementation guides. Notwithstanding the foregoing, neither Security Health Plan nor the affiliated provider shall (and this section shall not, in any way, be deemed or construed to):
- change any standard transaction definition, data condition or use of a data element or segment
- add any data elements or segments to the maximum defined data set
- use any code sets or data elements that are marked “not used” or do not appear in the implementation guide, or
- change the meaning or intent of any of the DHHS transaction standard’s implementation specifications.
Systems operation
Security Health Plan and the affiliated provider are responsible for ensuring that it or its providers can effectively and reliably transmit and receive EDI documents and shall be liable for the acts or omissions of its providers while transmitting, receiving, storing or handling standard transactions, or performing related activities. If Security Health Plan and the affiliated provider use the same provider to effect the transmission and receipt of a standard transaction, the originating party shall be liable for the acts or omissions of the provider as to such standard transaction.
Allocation of costs
Security Health Plan and the affiliated provider shall be responsible for the payment of its own fees and other charges incurred or assessed by it in transmitting or receiving EDI documents, including, without limitation, those fees charged by any of its providers.
Test modification
If Security Health Plan or the affiliated provider (the “requesting party”) applies to DHHS and obtains, for testing purposes, an exception from the use of a standard transaction, the requesting party shall provide the other party 30 days’ prior written notice of such exception. Effective at the end of such 30-day period, the other shall modify its transmission and/or receipt of documents to comply with the granted DHHS exception. If this occurs, trading partner agrees that it will participate in such test modifications.