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HIPAA Administrative Simplification

HIPAA Administrative Simplification. Final Rule for Transactions Code Sets Stanley Nachimson CMS snachimson@cms.hhs.gov. Transaction Standards Final Rule. Authority - HIPAA, 1996 Title II Rule Published August 17, 2000 Applies to covered entities: Health plans

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HIPAA Administrative Simplification

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  1. HIPAA Administrative Simplification Final Rule for Transactions Code Sets Stanley Nachimson CMS snachimson@cms.hhs.gov

  2. Transaction StandardsFinal 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.

  3. 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

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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

  9. Standards Adopted • Transactions: • Claims: • Retail pharmacy drug claims - NCPDP Telecommunications 5.1, Batch 1.0 • Professional, Dental, Institutional - X12N 837 4010 Implementation Guides

  10. Standards Adopted • Eligibility Inquiry and Response • Retail Pharmacy - NCPDP Telecommunications 5.1, Batch 1.0 • Dental, professional, institutional - X12N 270/271 4010 Implementation Guide

  11. 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

  12. Standards Adopted • Enrollment and Disenrollment in a Health Plan • X12N 834 4010 Implementation Guide • Payment and Remittance Advice • X12N 835 4010 Implementation Guide

  13. 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

  14. Code Sets Adopted • Diagnoses and inpatient hospital services - ICD-9-CM • Drugs, biologics - NDC codes • Dental services - CDT • Physician and all other services - CPT-4/HCPCS

  15. 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

  16. Medicare Actions • Detailed Instructions to Contractors • Minimize impact on internal processing • Provider testing to begin by Jan 2, 2002

  17. Other Rules for HIPAA Standards • Privacy • Security • NPI • Employer ID • Attachments, Plan ID, Enforcement.

  18. 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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