HIPAA Testing and Certification

HIPAA Testing and Certification (New Jersey Medicaid 5010 Guides)

HIPAA Testing and Certification requires each prospective electronic data interchange (EDI) submitter to be certified and approved before HIPAA transactions will be processed in production. The Workgroup for Electronic Data Interchange (WEDI), through a collaborative healthcare industry effort called the Strategic National Implementation Process (SNIP), has recommended six types of transaction testing:

  1. 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 syntax, and compliance with X12 rules. This will validate the basic level integrity of the EDI submission.
  2. Requirement Testing: Testing for HIPAA Implementation Guide-specific syntax requirements, such as repeat counts, used and not used codes, elements and segments, required or intra-segment situational data elements. Testing for non-medical code sets as laid out in the implementation guide. Values noted in the implementation guide via an X12 code list or table.
  3. Balance Testing: Testing the transaction for balanced field totals, financial balancing of claims or remittance advice, and balancing of summary fields, if appropriate.
  4. Situational Testing: Testing of specific inter-segment situations described in the HIPAA Implementation Guide, including the validation of situational fields based on rules present in the Implementation Guide for loops, segments, and data elements. For example, if data element A is valued then data element B must also be valued.
  5. External Code Set Testing: Testing for valid Implementation Guide-specific code set values. This level will not only validate the code sets but also make sure the usage is appropriate for any particular transaction.
  6. Specialty of Line of Business Testing: Testing to ensure that the segments and data elements required for certain healthcare services are present and correctly formatted according to the Implementation Guide.

New Jersey Medicaid will require each prospective EDI Submitter to certify their capability to produce 837 transactions for all six levels of the transaction testing types. This certification must be obtained from a thirdparty vendor (a list of vendors is provided later in this section). It is worth noting that some vendors have added a seventh type of testing that ensures the segments and data element requirements, specific to a trading partner (such as New Jersey Medicaid) are present and correctly formatted. DXC Technology will publish the names of vendors who successfully test to the seventh level of testing. Although New Jersey Medicaid does not require the seventh level at this time, it is definitely a benefit for the submitter to consider when selecting a vendor for certification. A separate certification will be required for the 837 Institutional, 837 Dental, and 837 Professional transaction sets. Once a certification is validated, the submitter will be placed into production.

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

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