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HIPAA Summit Audioconference Analysis of Addenda to HIPAA Transactions and Code Sets Rule. Larry Watkins Executive Vice President, Claredi Co-chair, WEDI SNIP Co-chair, X12N Health Care Task Group Member, DSMO Steering Committee February 27, 2003. Transaction Addenda guides.

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HIPAA Summit AudioconferenceAnalysis of Addenda to HIPAA Transactions and Code Sets Rule

Larry Watkins

Executive Vice President, Claredi

Co-chair, WEDI SNIP

Co-chair, X12N Health Care Task Group

Member, DSMO Steering Committee

February 27, 2003


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Transaction Addenda guides

  • X12N Version 4010A1 Implementation Guides

    • Work started October 2000

    • First drafts completed June 2001

    • NPRM published May 31, 2002

    • Small changes in response to NPRM comments

      • NDC, Taxonomy, anesthesia, etc.

    • Published November 7, 2002

  • Final Rule published February 20, 2003

    • Adopts 4010A1 as standard versions for 10/16/03 compliance


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Transaction schedule

  • X12N Implementation Guides for HIPAA

    • May 2000

      • Current version mandated for 10/16/02

      • Expected to be obsolete on 10/16/03

    • Addenda A1

      • Published November 2002

      • Final Rule released in February 2003

      • Implementation required by 10/16/03

      • Mandated modification of the May 2000 version


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PROVIDERS

INSURANCE AND PAYERS

SPONSORS

834

270

Eligibility

Verification

Enrollment

Enrollment

271

820

Pretreatment

Authorization

and Referrals

Precertification

and

Adjudication

278

Service Billing/

Claim Submission

Claim Acceptance

837I,P,D

276

Claim Status

Inquiries

Adjudication

277

Accounts

Receivable

Accounts Payable

835


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PROVIDERS

INSURANCE AND PAYERS

SPONSORS

834A1

270A1

Eligibility

Verification

Enrollment

Enrollment

271A1

820A1

Pretreatment

Authorization

and Referrals

Precertification

and

Adjudication

278A1

Service Billing/

Claim Submission

Claim Acceptance

837A1

276A1

Claim Status

Inquiries

Adjudication

277A1

Accounts

Receivable

Accounts Payable

835A1


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Why?

  • The May 2000 versions of the guides have severe flaws.

    • Addenda changes only the most critical errors “required for implementation”

    • Most significant changes are to the 837’s and the 278

  • Other errors and omissions will be corrected in version 4050


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Future of transactions

  • Version 4050 guides in development

    • Out for public comment in March 2003

    • Informational Forums in June during X12 (Nashville, TN)

    • Expected approval in June 2003

      • Will they be adopted under HIPAA?


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New transactions in 4050

  • Available for voluntary use (not mandated at this time)

    • Claim Acknowledgement 277

    • Coordination of benefits 269

    • IG Error Reporting 824

    • Eligibility Roster 271

    • Claims Attachments 275

    • Referral Attachments 275

    • Prescriptions (NCPDP Script)


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X12N Version 4050 Guides

  • New functionality being added to transactions

    • Guide (275) for attachments to a 278 referral request

    • Guide (824) for standardized acknowledgments approved

    • Changes to claims attachments (275/HL7) solution

  • Other versions will follow

  • Working with HHS and WEDI to improve/expedite regulatory process


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Implementation Guide Interpretations

  • Ambiguous situational language

    • Companion Documents necessary

  • Interpretive issues minimal

    • Education a more significant factor

  • X12N IG Interpretation Work Group

    • CMS has requested help from X12 on IG interpretation questions

    • Single site to post questions

    • Central place to obtain answers

    • Expected in place by June 2003


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Testing the Addenda Versions

  • Must test Addenda version

    • Requirement differences from May 2000 version

    • Especially 837’s and 278

  • Is testing of vendor, billing service, or clearinghouse enough?

    • Specific business process differences

      • Examples: Referring Dr., Secondary payer, Patient relationship to Subscriber

    • Entire process must be tested:

      Data collection

       Data formatting

       Reformatting (if applicable)

       Trading partner acceptance


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HIPAA TransactionTesting

  • Finite period of time to HIPAA deadline

    • Testing must start by April 16, 2003

  • Limited resources (internal & external)

  • Expected testing bubble in late 2003

  • Testing and production have conflicting requirements

    • Testing: detect and reject errors proactively

    • Production: accept maximum number of claims. Keep low rejection levels.


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Compliant, or not Compliant?

  • What is compliance?

  • What is a “transaction”?

  • Contingency Planning

    • New Formats

    • New Business Process

      • New data elements

      • New data requirements (situational)

    • Big switch, or progressive steps?

      • HIPAA compliance or continued business?

    • WEDI White Paper being drafted


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