|
HIPAA REGULATIONS: TRANSACTIONS AND CODE SETS
The original Transaction and Code Set regulation
compliance date was October 16, 2002. However, recent legislation
allows covered entities to delay the effective date until October
16, 2003 provided they submit a compliance plan to the Secretary
of DHHS prior to the original due date (October 16, 2002). The compliance
plan must demonstrate an entity's plan to pilot electronic transactions
by April 2003.
The EDI Transaction and Code Set standards only
cover transactions that are sent digitally and do not apply to paper
transactions. Electronic transmissions include those conducted over
the Internet, dial-up or leased lines as well as via private networks.
Furthermore, these standards cover transactions that occur, or are
transported, via magnetic tape, disk or CD media; although, telephone
and fax responses are not currently included. There are presently
more than 400 EDI formats in use by various payors. The new transaction
and code set regulations will standardize both financial and administrative
transactions, as well as the data elements required to conduct these
electronic transactions. The following healthcare transaction standards
have been specified in the HIPAA regulations:
| ASC X12N 837 |
Health claims or equivalent encounter
information |
| ASC X12N 835 |
Payment and remittance advice |
| ASC X12N 276/277 |
Claim status request and response |
| ASC X12N 834 |
Enrollment and disenrollment
in a health plan |
| ASC X12N 270/271 |
Eligibility benefit inquiry and
response |
| ASC X12N 820/811 |
Premium payment order/remittance
advice |
| ASC X12N 278 |
Referral certification and authorization |
| ASC X12N 275 |
Patient information/attachments
(No compliance date set) |
| ASC X12N 148 |
First report of injury (No compliance
date set) |
HIPAA mandates that covered entities transmitting
electronically, adopt the standard transaction formats and their
implementation guidelines. However, HIPAA does not require covered
entities to convert from paper to electronic transactions. Nor does
it mandate that providers submit these electronic transactions directly
to payors. Providers can use, or continue to use a clearinghouse
to format transactional data into the compliant format. Whether
a provider transmits directly or uses a clearinghouse to interface
with payors, it is critical for providers to understand that the
new transaction formats may require additional data elements, not
previously collected. Therefore, providers must be aware of the
data format requirements in order to send only the necessary information
required to process the specified transaction.
|
