HIPAA EDI Transactions Must Comply with Specific Rules and Guidelines

HIPAA EDI transactions must comply with specific rules and guidelines. The HIPAA transaction standards are outlined in the HIPAA Administrative Simplification regulation, which requires healthcare providers to use standardized electronic transactions for certain administrative functions.

To ensure compliance, healthcare providers must use the HIPAA standards for electronic data interchange (EDI) transactions, including claims, eligibility, and claim status inquiries. These standards are outlined in the HIPAA Implementation Guide for Electronic Data Interchange (EDI) Transactions.

HIPAA EDI transactions require the use of specific data elements and formats, such as the ANSI X12 standard for claims and eligibility inquiries. The HIPAA Implementation Guide provides a detailed explanation of the required data elements and formats for each type of transaction.

HIPAA EDI transactions must comply with standardized electronic data interchange (EDI) formats to ensure efficient and secure exchange of health-related administrative information. The HIPAA transactions and code sets regulations standardize the electronic exchange of health-related administrative information, such as claims forms.

A total of six standardized transaction formats will replace the hundreds of proprietary transactions currently in use. These transactions include claim/encounter, eligibility inquiry and response, claim status inquiry and response, referrals and prior authorizations, health care payment and remittance advice, and health claims attachments.

The following table lists the HIPAA-standard transactions that most medical practices will be required to use beginning Oct. 16:

HIPAA requires all private sector health plans, government health plans, health care clearinghouses, and health care providers to use standardized transactions when conducting electronic transactions.

The HIPAA transactions and code sets regulations standardize the electronic exchange of health-related administrative information, such as claims forms.

Here are the HIPAA-standard transactions that most medical practices will be required to use:

The health care industry recognizes the benefits of EDI and many entities in that industry have developed proprietary EDI formats, but standardization is necessary to achieve efficiency and savings.

The HIPAA standards are adopted by the Secretary of Health and Human Services, and covered entities must conduct transactions using these standards when they are initiated by a covered entity or its business associate, and the transaction is one for which a standard has been adopted.

A health plan may not delay or reject a standard transaction on the basis that it contains data elements not needed or used by the health plan, and may not charge fees or costs in excess of the fees or costs for normal telecommunications when receiving a standard transaction.

Kaiser Permanente requires the provider taxonomy code for claims adjudication. This code is necessary to identify the provider type and is a required field according to the ANSI 837 Claim Implementation Guide.

To identify a provider as submitter, you'll need to use one of the following codes: ISA06 (Interchange Sender ID), GS02 (Application Sender's Code), or NM109, Loop 1000A (Submitter Primary ID).

Health care providers must comply with the requirements of this subpart no later than July 30, 2004. This means that by this date, all health care providers must have implemented the standard unique employer identifier.

Health plans other than small health plans must also comply by July 30, 2004. Small health plans, however, have a bit more time to get on board.

Health care clearinghouses must comply with the requirements of this subpart no later than July 30, 2004. This date applies to all health care clearinghouses, regardless of size or scope.

The regulatory framework for HIPAA EDI transactions is quite complex, but don't worry, I've got the lowdown. A covered entity that is a covered health care provider must conduct transactions as standard transactions if they use electronic media with another covered entity that is required to comply with a transaction standard adopted under this part.

The Secretary adopts standards for covered entities, and these standards must be followed for certain transactions. For example, if a covered entity conducts a transaction for which a standard has been adopted under this part, they must conduct the transaction as a standard transaction.

A health care provider electing to use direct data entry offered by a health plan must use the applicable data content and data condition requirements of the standard when conducting the transaction, but they are not required to use the format requirements of the standard.

A covered entity may use a business associate, including a health care clearinghouse, to conduct a transaction covered by this part. If a covered entity chooses to use a business associate to conduct all or part of a transaction on behalf of the covered entity, the covered entity must require the business associate to comply with all applicable requirements of this part.

The business associate must also require any agent or subcontractor to comply with all applicable requirements of this part.

Transaction Content is crucial for HIPAA EDI transactions. Data content standardization is key, and we proposed standard data content for each adopted standard.

Data elements must be governed by the principle of a maximum defined data set, which means no one can exceed the maximum defined data set in this rule. This principle applies to the data elements of all transactions.

Data conditions are rules that define when a particular data element or segment can or must be used.

Data content is a crucial aspect of transaction content. It's essential to have a standardized data set to ensure identical implementations.

The proposed data content includes implementation specifications, data conditions, data dictionaries, and standard code sets for medical data. This ensures that all data elements are governed by a maximum defined data set.

No one can exceed the maximum defined data set, which applies to all transactions. This principle is a key component of data content standardization.

Data conditions are rules that define when a particular data element or segment can or must be used. These rules are essential for ensuring accurate and consistent data exchange.

The Internet site for the American Medical Association is http://www.ama-assn.org. This resource can provide valuable information on data content and standardization.

The equivalent encounter information is essentially a report of health care services provided, transmitted to a health plan for the purpose of reporting health care.

This type of transaction is used when there's no direct claim, such as when reimbursement is based on a mechanism other than charges or reimbursement rates for specific services.

The equivalent encounter information transaction is the transmission of encounter information, as stated in § 162.1101.

For example, this type of transaction is used for institutional health care claims, where the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3—Health Care Claim: Institutional (837) is used, as seen in example 2.

The transaction is also used for professional and institutional request for review and response, where the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3—Health Care Services Review—Request for Review and Response (278) is used, as seen in example 1.

This type of transaction is an important part of the health care claims process, allowing health plans to accurately report and process health care services provided.

Trading Partner Agreements are a crucial aspect of HIPAA EDI transactions. You don't need to sign a special trading partner agreement with Kaiser Permanente if you submit via a clearinghouse.

However, if you're a non-contracted provider, vendor, or other entity, you'll need to sign the appropriate business associate and security agreements. This is a requirement for those not directly contracted with Kaiser Permanente.

Most questions about trading partner agreements should be directed to your clearinghouse, as they'll be testing with it and meeting requirements established by the clearinghouse.

As you navigate the world of trading partner agreements, it's essential to understand the requirements for use. All private sector health plans, including managed care organizations and ERISA plans, and government health plans, such as Medicare, must use the standards when conducting any of the defined transactions covered under HIPAA.

These "covered entities" must use the standards when conducting transactions electronically, which includes health claims and equivalent encounter information, enrollment and disenrollment in a health plan, eligibility for a health plan, health care payment and remittance advice, health plan premium payments, health claim status, referral certification and authorization, and coordination of benefits.

A health care clearinghouse may accept nonstandard transactions for the sole purpose of translating them into standard transactions for sending customers and may accept standard transactions and translate them into nonstandard transactions for receiving customers.

Health plans must be able to support the electronic standard for each transaction, either directly or through a clearinghouse. This means they must be able to accept and promptly process any standard transaction that contains valid codes.

Here are the administrative and financial health care transactions that are required to use the standards:

Health plans may not delay or reject a standard transaction on the basis that it contains data elements not needed or used by the health plan, such as coordination of benefits information.

If you're a Kaiser Permanente contracted provider, you don't need a special trading partner agreement with Kaiser Permanente to exchange transactions directly. However, other entities like non-contracted providers, vendors, and so on, must sign the appropriate business associate and security agreements.

Your clearinghouse will be your primary point of contact for testing and meeting requirements, so most questions should be directed to them. If you decide to exchange files directly with Kaiser Permanente, call the PAU or email EIS Support.

A trading partner agreement with Kaiser Permanente is not required if you submit EDI transactions through a clearinghouse. Your agreement will be directly with the clearinghouse in this case.

Kaiser Permanente requires the provider taxonomy code for claims adjudication, which is a required field that needs to be populated according to the ANSI 837 Claim Implementation Guide.

The following fields are used to identify a provider as submitter:

As you navigate the world of trading partner agreements, it's essential to have a clear understanding of what your vendor can offer.

Ask your vendor if the version of your software product will be able to send a claim/encounter form in the HIPAA standard X12-837 content and data format to all payers.

Your vendor should be able to confirm if their transactions have been tested and certified by a third party as offering a "HIPAA-compliant" software modification.

You should also ask for a specific date when your vendor will be ready to upgrade your system, as this will impact your implementation timeline.

In some cases, the modifications may require a new version of your practice management software, so be sure to ask about this as well.

You may also need to consider whether any new hardware will be required to support the modifications, so don't hesitate to ask about this.

Training will likely be provided, but be sure to ask when and how it will be delivered.

Your vendor should also be able to provide a schedule for internal testing, testing with a clearinghouse, testing with Medicare, and testing with commercial payers.

You may be able to upgrade to the various standards incrementally, so ask if this is an option and what the process would look like.

Finally, ask about the expected costs associated with the modifications and upgrades.

Here are some key questions to ask your vendor, summarized in a list:

The inventory worksheet is a crucial tool for prioritizing your efforts in complying with the HIPAA transactions and code sets standards. It helps you organize pertinent information about each payer or health plan to which you submit electronic claims.

To use the worksheet effectively, start by listing each payer or health plan to which you currently submit or plan to submit electronic claims. The worksheet will guide you in gathering information such as the number of claims sent, dollar amount, and percent sent electronically or on paper.

The worksheet also includes a section for tracking errors, which is essential for identifying areas where you need to improve your compliance. For example, you can use this section to note any errors that have occurred with Medicare or Medicaid claims.

Here's a sample worksheet layout:

This layout will help you keep track of your claims submissions and identify areas where you need to improve your compliance. By using the inventory worksheet, you'll be better prepared to speak with your vendors about their HIPAA-readiness.

Kaiser Permanente requires the provider taxonomy code for claims adjudication.

This code is used to identify the provider type, and it's a required field according to the ANSI 837 Claim Implementation Guide.

To identify a provider as submitter, you'll need to use one of the following:

Kaiser Permanente uses the ANSI 837 Health Care Claims transaction to process claims, and payors are identified by a unique number, which may vary by clearinghouse. The payor number for Kaiser Permanente is 91051.

To submit a claim, providers must use the correct frequency code. For late charges, frequency code 5 is no longer valid, and providers must use frequency code 7 to submit a corrected claim.

DME items require a specific code, which is required for all DME items.

Here are the required data elements to search eligibility on the Contracted Providers website:

To determine past eligibility, change the date of service to the date in question.

To conduct an eligibility and benefits inquiry, you'll need to use the ANSI 270/271 transaction, which requires three out of the four data elements: Member ID, First name, Last name, and Date of birth.

The 271 Eligibility and Benefits Response will provide information on Member Demographic Information, Primary Kaiser Permanente Coverage, Secondary Kaiser Permanente Coverage, and PCP Information.

For a quick search, use either the patient account number or the claim number, or search using any combination of Member ID, First name, Last name, and Date of birth.

The Secretary adopts the following standards for the eligibility for a health plan transaction: Retail pharmacy drugs, Dental, professional, and institutional health care eligibility benefit inquiry and response, and Coordination of benefits transaction.

The eligibility for a health plan transaction is the transmission of an inquiry from a health care provider to a health plan, or from one health plan to another health plan, to obtain information about a benefit plan for an enrollee.

Here are the required data elements for the 270/271 transaction:

The 271 Eligibility and Benefits Response will include the following information:

Referral certification and authorization transactions are a crucial part of HIPAA EDI transactions.

A request from a healthcare provider to a health plan for review of healthcare to obtain an authorization for the healthcare is considered a referral certification and authorization transaction.

Kaiser Permanente uses the ANSI 278 Referral Certification, Authorization Request, and Response standard for these transactions.

Batch referral requests will generate batch responses from Kaiser Permanente, so follow-up calls from providers are usually not necessary.

The referral certification and authorization transaction is defined in the HIPAA regulations as any transmission of a request from a healthcare provider to a health plan for review of healthcare, or a response from a health plan to a healthcare provider.

The Secretary has adopted standards for the referral certification and authorization transaction, which include the NCPDP Telecommunication Standard Implementation Guide and the ASC X12N 278 standard.

Retail pharmacy drug referral certification and authorization, as well as dental, professional, and institutional referral certification and authorization, are subject to specific standards.

The health care claim status transaction is a transmission of either an inquiry from a health care provider to a health plan to determine the status of a health care claim, or a response from a health plan to a health care provider about the status of a health care claim.

A health plan premium payment transaction is the transmission of payment, information about the transfer of funds, detailed remittance information, or payment processing information to transmit health care premium payments.

The standards for the health plan premium payments transaction include the ASC X12N 820—Payroll Deducted and Other Group Premium Payment for Insurance Products, Version 4010, and the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3—Payroll Deducted and Other Group Premium Payment for Insurance Products.

A paper remittance advice form will only be sent upon request, as InstaMed acts as the clearinghouse to distribute electronic remit advice and other payments.

If you're a provider, you'll need to submit test claims using Kaiser Permanente's test members in order to receive a paper remittance advice form.

Kaiser Permanente will process COB claims if it's the secondary payor, as long as the claim is submitted in accordance with the Forum Administration Simplification Policies and Guidelines.

However, if Kaiser Permanente is the primary payor, you'll need to submit the secondary claim in accordance with the guidelines of the secondary payor.

You can request a crosswalk, but it will be of limited value due to the many-to-one relationship between prior Kaiser Permanente action codes and 835 Adjustment Reason codes.

The ASC X12N 835—Health Care Claim Payment/Advice, Version 4010, is the standard for health care claims and remittance advice from October 16, 2003 through March 16, 2009.

This standard is incorporated by reference in § 162.920, and is still used for certain periods and transmissions.

On and after January 1, 2014, the Secretary adopts the Phase III CORE EFT & ERA Operating Rule Set, which includes the Phase III CORE 380 EFT Enrollment Data Rule, version 3.0.0, June 2012.

This rule set also includes the CORE-required Code Combinations for CORE-defined Business Scenarios for the Phase III CORE 360 Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule, version 3.0.0, June 2012.

A claim is a request for payment or reimbursement from a health plan.

The health care claim status transaction is used to determine the status of a claim.

This transaction can be initiated by a health care provider sending an inquiry to a health plan.

A response from the health plan provides information about the status of the claim.

The status of a claim can be one of several things, but the health care claim status transaction helps to clarify what's going on.

The transaction is used for both inquiries and responses, making it a vital part of the claims process.

Premium Payments are a crucial part of the claims process, and understanding how they work can make a big difference in getting your healthcare needs met.

The health plan premium payments transaction involves transmitting payment and related information from the entity providing health care coverage to a health plan. This can include payment, information about the transfer of funds, detailed remittance information about individuals, and payment processing information.

For the period from October 16, 2003 through March 16, 2009, the standard for this transaction was the ASC X12N 820—Payroll Deducted and Other Group Premium Payment for Insurance Products, Version 4010.

The standard for the health plan premium payments transaction includes the ASC X12N 820—Payroll Deducted and Other Group Premium Payment for Insurance Products, Version 4010, and the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3—Payroll Deducted and Other Group Premium Payment for Insurance Products (820), February 2007.

The health plan premium payment transaction can also involve associated group premium payment information, which is an important part of the process.

Electronic funds transfers are a crucial aspect of HIPAA EDI transactions. The transmission of payment and explanation of benefits from a health plan to a health care provider is a key example of this.

For the period from October 16, 2003 through March 16, 2009, the standard for health care claims and remittance advice was the ASC X12N 835—Health Care Claim Payment/Advice, Version 4010, May 2000.

The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3—Health Care Claim Payment/Advice (835), April 2006, is the standard for the period from January 1, 2012 through December 31, 2013. This standard is still applicable today for certain transmissions.

On and after January 1, 2014, the Secretary adopted the Phase III CORE EFT & ERA Operating Rule Set, Approved June 2012, which includes the Phase III CORE 370 EFT & ERA Reassociation (CCD+/835) Rule, version 3.0.0, June 2012.

State Medicaid programs are identified as health plans under HIPAA, which means they must be capable of receiving, processing, and sending standard transactions electronically. This includes claim, encounter, enrollment, eligibility, remittance advice, and other transactions.

Medicaid programs will benefit from the national standard for encounter transactions, which will provide a much-needed method for collecting encounter data on Medicaid beneficiaries enrolled in managed care. This will enhance the ability to monitor utilization, costs, and quality of care in managed care and compare it with fee-for-service.

The standard transactions will also include methods for electronic exchange of enrollment information between Medicaid programs and private managed care plans, reducing administrative costs and enhancing the reliability of such information. Additionally, Medicaid programs can shift to commercial software or clearinghouses and stop maintaining old, customized transaction systems, which can be expensive to maintain.

Here are some specific Medicaid requirements:

Medicaid programs must be capable of receiving, processing, and sending standard transactions electronically, just like private health plans. This includes claim, encounter, enrollment, eligibility, remittance advice, and other transactions.

As health plans, Medicaid programs must comply with other HIPAA standards two years after adoption of the standards. This will require them to have the capacity to process standard transactions electronically.

The standards will benefit Medicaid programs in several ways, including providing a national standard for encounter transactions. This will enable the collection of encounter data on Medicaid beneficiaries enrolled in managed care.

Medicaid programs will be able to combine encounter data from managed care with similar claims data from fee-for-service. This will enhance the ability to monitor utilization, costs, and quality of care in managed care and to compare managed care with fee-for-service.

The standard transactions will include methods for electronic exchange of enrollment information between the Medicaid program and private managed care plans enrolling Medicaid beneficiaries. This will reduce administrative costs of exchanging such information and enhance the reliability of such information.

Medicaid programs will also have the opportunity to shift to commercial software or clearinghouses and stop the expensive maintenance of old, customized transaction systems. This can help reduce costs and improve efficiency.

Here are some specific transactions that Medicaid programs must be able to process electronically:

Medicaid Pharmacy Subrogation is a process where a Medicaid agency seeks reimbursement from a responsible health plan for a pharmacy claim they've paid on behalf of a Medicaid recipient.

This process involves the transmission of a claim from the Medicaid agency to the payer, which is known as the Medicaid pharmacy subrogation transaction.

The transmission of this claim is guided by a standard, which is the Batch Standard Medicaid Subrogation Implementation Guide, Version 3.0, July 2007, National Council for Prescription Drug Programs.

For covered entities that are not small health plans, this standard applies starting from January 1, 2012.

For small health plans, the standard applies starting from January 1, 2013.

A health care clearinghouse must use the NPI of any health care provider to identify that provider on all standard transactions where the provider's identifier is required.

Clearinghouses have specific rules to follow, such as implementing an appeals process for decisions made on requests.

They must also ensure that standard transactions are translated correctly, whether receiving a standard transaction on behalf of a covered entity or translating a nonstandard transaction into a standard one.

In addition to these requirements, clearinghouses must also meet certain standards, including being uniform and consistent with other adopted standards, having low additional development and implementation costs, and being technologically independent.

A health care clearinghouse must use the NPI of any health care provider to identify that provider on all standard transactions where the provider's identifier is required.

To identify a health care provider, a clearinghouse must use the National Provider Identifier (NPI) assigned to the provider. This ensures accurate and efficient communication between providers and payers.

A health care clearinghouse may perform various functions when acting as a business associate for another covered entity, including receiving and translating standard and nonstandard transactions.

These functions include receiving a standard transaction and translating it into a nonstandard transaction, and receiving a nonstandard transaction and translating it into a standard transaction for transmission.

The proposed modification to the standard transaction must include specifications for any additional system requirements, and testing of the modification must be explained in a 5-page document.

The testing plan should include the number and types of health plans and healthcare providers expected to be involved, geographical areas, and the beginning and ending dates of the test.

The standard must be uniform and consistent with other standards adopted under this part, and must be supported by an ANSI-accredited SSO or other private or public organization that would maintain the standard over time.

The standard should be technologically independent of computer platforms and transmission protocols used in electronic health transactions, unless they are explicitly part of the standard.

The standard should result in minimum data collection and paperwork burdens on users, and incorporate flexibility to adapt to changes in the healthcare infrastructure and information technology.

Health care clearinghouses can perform certain functions when acting as a business associate for another covered entity, including translating standard transactions into nonstandard ones and vice versa.

To ensure the success of electronic health care transactions, the standards adopted under this part must meet specific requirements. These include improving the efficiency and effectiveness of the health care system, meeting the needs of the health data standards user community, and being uniform and consistent with other standards.

A proposed modification to the standard must include specifications for the proposed modification, including any additional system requirements. This will help organizations understand what changes are being made and how they will affect their systems.

Organizations must also provide an explanation of how they intend to test the proposed modification. This explanation should not exceed 5 pages in length and should include details such as the number and types of health plans and healthcare providers involved in the test, geographical areas, and test dates.

The operating rules for health care claim status transactions are specified in the CAQH CORE Phase II operating rules, which include the Claim Status Rule and the CORE v5010 Master Companion Guide.