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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 Audioconference Analysis of Addenda to HIPAA Transactions and Code Sets Rule


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    1. 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

    2. 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

    3. 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

    4. 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

    5. 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

    6. 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

    7. 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?

    8. 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)

    9. 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

    10. 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

    11. 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

    12. 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.

    13. 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