Transcript HIPAA Administrative Simplification

HIPAA Administrative
Simplification
Final Rule for
Transactions
Code Sets
Stanley Nachimson
CMS
[email protected]
Transaction Standards
Final Rule
Authority - HIPAA, 1996 Title II
 Rule Published August 17, 2000
 Applies to covered entities:
Health plans
Health care clearinghouses
Health care provider who transmits
electronic transactions.

Provisions of the Rule
Covered entities must comply by Oct 16,
2002 (except small plans - Oct 16, 2003)
 DSMOs maintain standards
 Process for new standards or modifications
Request to DSMOs
Recommendation to NCVHS
Rulemaking

Provisions of the Rule
Trading Partner agreements cannot change
the standards.
 Covered entities conducting transactions
with each other (or within themselves) must
use the standards.
 Direct data entry must meet content, not
format.
 Covered entities can use business associates
to conduct transactions.

Provisions of the Rule (Health
Plans)
If requested by any entity, a health plan
must conduct a transaction as a standard
transaction.
 Health plans cannot delay transactions
because they are standard
 Health plans cannot reject standard
transactions because they contain data
elements not used by the plan.

Provisions of the Rule (Health
Plans)
Health plans cannot offer incentives for
direct data entry.
 Health plans operating as clearinghouses or
requiring the use of a clearinghouse cannot
charge extra fees beyond normal
transmission costs.
 COB data must be stored.
 Use the standard code sets and keep current.

Provisions of the Rule (Health
Care Clearinghouses)

As a business associate, a clearinghouse
can:
Receive a standard transaction and
translate it into a non-standard
transaction.
Receive a non-standard transaction and
translate it into a standard transaction.
Provisions of the Rule

An exception may be granted to test a
proposed modification to the standard
Request made to the Secretary
Test must be conducted
Report on test results made
Standards Adopted

Transactions:
Claims:
Retail pharmacy drug claims - NCPDP
Telecommunications 5.1, Batch 1.0
Professional, Dental, Institutional X12N 837 4010 Implementation
Guides
Standards Adopted

Eligibility Inquiry and Response
Retail Pharmacy - NCPDP
Telecommunications 5.1, Batch 1.0
Dental, professional, institutional X12N 270/271 4010 Implementation
Guide
Standards Adopted
Referral Certification and authorization
Retail pharmacy - NCPDP
Professional, Dental, Institutional - X12N
278 4010 Implementation Guide
 Claims status inquiry and response
X12N 276/277 4010 Implementation
Guide

Standards Adopted

Enrollment and Disenrollment in a Health
Plan
X12N 834 4010 Implementation Guide

Payment and Remittance Advice
X12N 835 4010 Implementation Guide
Standards Adopted

Health Plan Premium Payments
X12N 820 4010 Implementation Guide

Coordination of Benefits
Retail pharmacy drug claims - NCPDP
Telecommunications 5.1, Batch 1.0
Dental, professional, institutional claims X12N 837 4010 Implementation Guides
Code Sets Adopted
Diagnoses and inpatient hospital services ICD-9-CM
 Drugs, biologics - NDC codes
 Dental services - CDT
 Physician and all other services - CPT4/HCPCS

Implementation Considerations
Accepting and sending transactions translator, clearinghouse, system change
 Changes in data content in standard
transactions - gap analysis
 Alignment with paper processes
 Elimination of local codes
 Coordination among plans and payer - SNIP

Medicare Actions
Detailed Instructions to Contractors
 Minimize impact on internal processing
 Provider testing to begin by Jan 2, 2002

Other Rules for HIPAA Standards
Privacy
 Security
 NPI
 Employer ID
 Attachments, Plan ID, Enforcement.

Important Web Sites
DHHS Administrative Simplification FAQs, submit questions
aspe.hhs.gov/admnsimp
 Implementation Guides
www.wpc-edi.com/hipaa
 Implementation - SNIP at WEDI
www.wedi.org
 Standards Change Requests
www.hipaa-dsmo.org
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