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An Introduction To The HIPAA Electronic Data Interchange (EDI) Regulations
An Introduction To The HIPAA Electronic Data Interchange (EDI) Regulations
Presentation Agenda
Administrative Simplification Provisions Benefits of EDI EDI Key Business and IT Impacts
Standard Identifiers Code Sets Transaction Sets Introduction Transaction Sets
Next Steps
Internal External Communication
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Benefits of EDI
Reduction in manual data entry and processing Elimination of cost and delays of postal service Improved data comparability Elimination of disparate forms and codes Improved cash flow Improved accuracy of information Fewer claims rejections
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Covered Entities
Health plans Health care clearinghouses services that translate information between organizations Health care providers who transmit any health information in electronic form in connection with a covered transaction
Non-Covered Entities
Workers Compensation Programs Property and Casualty Programs Disability Insurance Programs Nursing Home Fixed Indemnity Policies Prisons
Requirements of Clearinghouses
A provider submitting standard transactions through a clearinghouse must not be adversely affected financially by doing so The cost of submission to a clearinghouse cannot exceed the cost of direct transmission to the health plan
Requirements of Providers
Must use standard transactions if conducted electronically MAY continue to use paper media MAY use a business associate to conduct a transaction MAY use a clearinghouse to translate nonstandard transactions
Standard Identifiers
HIPAA Proposed Standard Identifiers Potential Key Impacts Standard Identifiers
Individual
Format On hold due to privacy concerns
Code Sets
What is a Code Set? HIPAA Code Sets Key HIPAA Impacts - Code Sets Key IT and Business Impacts Code Sets
CPT-4:
NDC:
CDT-3:
Future claim submissions may require code plus modifier for services Number of diagnosis codes allowed on a submission will increase from 4 to 8 with 4 pointers per diagnosis for each service line on the claim
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Implementation Guides
Implementation Guides include:
Data elements required or conditionally required Definition of each data element Technical transaction formats for the transmission of the data Code sets or values that can appear in selected data elements
Implementation Guides are in PDF format X12N Implementation Guide downloads are free NCPDP Implementation Guides require a fee
Pharmacy Claims
National Council for Prescription Drug Programs
The final standards for electronic health care transactions, and for code sets, adopt the NCPDP Telecommunication Standard Format, Version 5.1 and the NCPDP Batch Standard, Version 1 Release 0 for pharmacy claims Health plans, health care clearinghouses and health care providers who utilize electronic transactions will be required to use these standards beginning October 2002 Application for an extension until October 2003 available from the DHHS website (due Oct 2002)
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Purpose Eligibility inquiry/response Authorization/referral Claim submission, 3 types: Institutional, Professional, and Dental Claim status inquiry/response Claim payment remittance Enrollment Premium payment
Transaction Sets
270/271 278
Health Plans
Enrollment Pre-certification / Adjudication
837
276/277
835
Accounts Payable
270/271:Eligibility Transaction
270 Eligibility Inquiry - A request sent by a provider for determination of eligibility 271 Eligibility Response - An information source that responds to the request with either an acknowledgement that the patient has active or inactive coverage, or that the patient was not found within their system
The transmission of either of the following from a health plan to a health care provider:
Explanation of benefits Remittance advice
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Health claims attachments following electronic claims with paper attachments does not make sense
Next Steps
Next Steps
Educate your staff Define an organizational EDI strategy and determine which transactions you want to process electronically using the standard formats Conduct a comprehensive analysis
Evaluate transactions and code sets currently in use Identify information systems and feeder systems Identify and begin discussions with trading partners and vendors Review contracts Identify process changes necessary
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Industry Collaboration
WEDI - Workgroup for Electronic Data Interchange: www.wedi.org SNIP - Strategic National Implementation Process: www.wedi.org/snip
SNIP is a collaborative health care industry-wide process resulting in the implementation of standards and furthering the development and implementation of future standards Many white papers available, written by industry collaborative effort:
Direct Data Entry (DDE) Coordination of Benefits (COB) Testing and certification
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Questions and Discussion Press 1 on your touch tone phone for questions.
Resources
American Health Information Management Association (AHIMA):
Benchmark information and case studies Interim Steps for Getting Started
http://www.ahima.org/hipaa.html
http://www.cpri-host.org http://aspe.hhs.gov/admnsimp/index.ht m
For the Record: Protecting Electronic Health Information (National Academy Press, 1997) 800-6246242
Full Report
http://www.nap.edu
HIPAA Transaction Implementation Guides from the Washington Publishing Company Links to federal HIPAA sites Subscribe to email release of HIPAA documents (such as notice of proposed rule making)
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