Type 5 HIPAA External Code Set Testing

Type 5 validation involves validating data content against code sets from external code sources as explicitly defined in the implementation guides for use with HIPAA standards. Examples of HIPAA X12 code sets include the 508 Health Care Claim Status Codes, that are available from Washington Publishing Company. Another example is the 537 National Provider Identifiers available from Centers for Medicare and Medicaid (CMS).

The options for reporting Type 5 exceptions include the HIPAA 999 implementation acknowledgment and the Translated Acknowledgment report.

Applicable Type 5 rules for the Claim Transactions (837) will now use the service date from the claim, and not the processing date, to determine if the code is valid for this particular date.

Date Segments used for Type 5 Validation

For Type 5 validation for codes within segments in the Claim (2300) Loop, such as HI:
  • Institutional Claim validation will use 2300 Statement Dates, DTP*434, which is a required segment and specifies a date range.
  • Professional Claim validation will use the range of dates from the earliest to latest Service Level Dates in the 2400 DTP*472.
  • Dental claim validation will use 2300 Service Date, DTP*472 if present, which can be a single date or a range. If this is not present the range of 2400 DTP*472 Service Dates will be used.
For Type 5 validation for codes within segments in the Service (2400) Loop, such as SV1, SV2, and SV3:
  • Institutional claim validation will use 2400 Service Date if present. If this is not present, the 2300 Statement Date DTP*434 will be used.
  • Professional claim validation will use Service Level Date in 2400 DTP*472.
  • Dental claim validation will use the 2400 Service Date, DTP*472 if present. If this is not present, the 2300 DTP*472 Service Date will be used.

Code list applicable for Service Date used in Type 5 Validation

The following code lists are used in fields present in the claim and service loops of claim transactions, which represent medical code sets that could have start and/or end dates for the code value usage.

For some of these, the default validation is Pattern Match as the Healthcare Pack does not include these code sets for licensing or other reasons. For the new Service Date functionality to be used with these, the user will need to load those code sets with included start and/or end dates, and update the corresponding rules to use CV or Code Value, instead of PM or Pattern Match.
Code source Description
130 Healthcare Common Procedural Coding System
131 International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
132 National Uniform Billing Committee
133 Current Procedural Terminology (CPT) Codes
135 American Dental Association
229 Diagnosis Related Group Number
240 National Drug Code by Format
513 Home Infusion EDI Coalition (HIEC) Product/Service Code List
576 Workers Compensation Specific Procedure and Supply Codes
716 Health Insurance Prospective Payment System (HIPPS) Rate Code for Skilled Nursing Facilities
843 Advanced Billing Concepts (ABC) Codes
896 International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
897 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)