What health care transactions
are required to use the standards under HIPAA?
As required by HIPAA, the Secretary of Health and Human Services
is adopting standards for the following administrative and financial
health care transactions:
- 837 — Health claims and equivalent
encounter information.
- 834 — Enrollment and disenrollment in a health plan.
- 270/271 — Eligibility for a health plan.
- 835 — Health care payment and remittance advice.
- 820 — Health plan premium payments.
- 276/277 — Health claim status.
- 278 — Referral certification and authorization.
- COB — Coordination of benefits.
I hear people talking
about the 835 transaction or the 270/271 pair of transactions. What
does that mean?
Transactions covered under HIPAA are often referred to by their
transaction set and version. Instead of saying “ASC X12N 837
004010 X098,” most people refer to that transaction as “837
institutional (/professional/dental).”
A listing of the transactions/transaction pairs adopted
as of this writing follows. For simplicity, transactions are identified
only by their transaction set:
- 837 Health Care Claim:
— Dental
— Professional
— Institutional
- 270/271 – Health Care Eligibility Benefit Inquiry and Response
- 278 – Health Care Services Review; Request for Review and
Response
- 276/277 – Health Care Claim Status Request and Response
- 834 – Benefit Enrollment and Maintenance
- 835 – Health Care Claim Payment/Advice
- 820 – Payroll Deducted and Other Group Premium Payment
for Insurance Products
What is the Implementation
schedule that MDCH is planning with the HIPAA claim and coding transactions?
There are nine (9) transactions that are included in HIPAA compliance.
MDCH will implement them incrementally beginning October 1, 2002
starting with claims and encounters:
- MDCH is currently conducting Business to Business (B2B) testing
for all 837 claim formats (Professional, Institutional, Dental).
- MDCH will accept all 837 v 4010 formats (except 837 Institutional
for Nursing Facilities) by October 1, 2002.
- MDCH has delayed the implementation of the ANSI ASC X12N 837
Institutional version 4010 claim transaction for Nursing Facilities
from October 1, 2002 to January 1, 2003 to allow additional time
for testing.
- MDCH will begin testing all remaining HIPAA compliant transactions
April 16, 2003.
- All transactions must be HIPAA compliant by October 16, 2003.
- Code sets will be standardized by October 16, 2003.
How do I decode the transaction
standards?
Transaction standards can be broken down into five parts. Example:
ASC X12N 837 004010 X098
- ASC – Source of a standard; in this case, the standard
comes from the American National Standards Institute (ANSI) Accredited
Standards Committee (ASC). This is occasionally shown as “ANSI
ASC” or just “ASC”. Both indicate the same source
of a standard.
- X12N – A subcommittee of the ANSI ASC X12 committee; the
X12N subcommittee defines EDI standards used in the insurance
industry.
- 837 – A transaction set; in the case of the 837 transaction,
institutional, professional, and dental variations exist. Each
one of these is addressed later in this answer.
- 004010 – Version of the X12 standard; this is usually referred
to as “version 4010”. It identifies version 4 of the
standard, Release 1, sub release 0.
- X098 – Internal reference numbers; in the case of the 837
transaction, three versions exist, institutional, dental and professional.
Reference numbers X096, X097, and X098 identify these, respectively.
Is sending data on a disc
considered an electronic transaction?,
Yes.
When are web-based transactions
considered to be part of Direct Data Entry systems, which are subject
only to the data content portions of the standards, and when are
they considered regular transactions which must meet both data content
and format requirements of the standards?
If the sender is using his or her browser to directly enter information
onto a server that is part of the receiver’s system, then it
is considered a direct data entry transaction, which need only meet
the data content and data condition requirements of HIPAA rules.
If, however, the data is entered onto a server, which is then repackaged
in order to send to the receiver’s system, now the data is
considered a transaction, which must be sent to the receiver in
a HIPAA compliant transaction format.
What is the difference
in an 837 encounter and an 837 claim?
Nothing except one is coded RP (for reporting) and the other is
coded CH (for charge). CH or RP is reflected in the date element
BHT06.
I would believe that any
fields that cannot be collected from a HCFA 1500, should be sorted
out from the 837 HIPAA IG, and reviewed. How can my providers submit
data they don't have. So either these fields have to be reviewed,
and a new form has to be created, or HIPAA is going to have to change
the dataset minimum required. Can someone shed some light on this?
HIPAA was not intended to cover paper transactions. It was intended
for electronic transactions and all necessary data elements to be
included in one file for complete processing. It is not enough for
providers to upgrade to a software version that is "HIPAA compliant",
or to use a clearinghouse that is compliant. Unless the provider
in question implements remediation steps that include capturing
the necessary data, that provider will still not be compliant even
if they are using the latest software or clearinghouse. HIPAA EDI
is not just about EDI format but also about the data content in
those EDI transactions. And the paper 1500 or UB92 claims do not
have everything that the EDI transactions need.
What are the different
adjudication requirements? Doesn’t HIPAA mandate all electronic
claims be standard?
HIPAA requires that all electronic claims be submitted in a standard
format and comply with all required data elements and those situational
data elements that are applicable based on the conditions described
in the HIPAA implementation guide. HIPAA does not impact payers’
coverage rules. The Medicare free billing software is being developed
to support the submission of Medicare HIPAA compliant claims only.
The software will not capture any of the situational data elements
that may apply to other payers, but not to Medicare. For example,
the professional HIPAA 837 implementation guide has fields for the
service authorization exception code and immunization batch number.
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