HIPAA Transaction Set Rules

In January 2009, U.S. Health and Human Services Department published final rules needed to adopt a revised Health Insurance Portability and Accountability Act, originally enacted by U.S. Congress in 1996. HHS adopted X12 5010 and NCPDP D.0 for HIPAA transactions. The standard for Medicaid subrogation of pharmacy claims, known as NCPDP Version 3.0, was also adopted.

Establishing HIPAA Transaction Set Rules potentially paves the way for smoother transmission of electronic medical records.

HIPAA Transaction Set Rules Reports

• The need to define universal transaction set codes establishes the beginnings of a more efficient and productive health care system. Without this foundation, coding errors and emissions stop patient information and payments.

  HHS modified standard code sets necessary for proper coding of patient hospital procedures and diagnoses in International Classification of Diseases, 10th Revision, Clinical Modification ICD-10-CM diagnosis codes, and International Classification of Diseases, 10th Revision, Procedural Coding System ICD-10-PCS of in-patient hospital procedures codes. Implementation for both revisions is October 1, 2013 for all health care entities, including hospitals, nursing homes, rehab centers, medical, dental and institutional services providers, pharmacies and others.

  The two rules include health care plans, clearinghouses and some providers. Compliance due dates for all entities close on January 1, 2012.

Important EDI Transactions

• Consult CMS's "Transaction Code Sets Standards" published in 2009. Important Electronic Data Interface transactions include:

  -- 837. Medical claims with institutional, dental or professional differences. This transaction set categorizes the submission of health care billing details and information, with the exception of retail pharmacy claims, and allows providers to directly invoice payers or to interact with clearinghouses and others engaged in billing.

  -- 820. Payroll-deducted and other group premium payments for insurance products. This category describes payment of insurance premiums or collection of premium payments from a bank to an insurer or insurer's agent.

  -- 834. Benefits enrollment and benefits maintenance. This category code, used by unions, government offices, agencies, and insurers to enlist members to payers or health care organizations administering benefits, insurance or claims, represents streamlined payment process.

  Payers include health maintenance organizations, preferred provider organizations, Medicare or Medicaid, or contractors and sub-contractors of these organizations and other government agencies.

  -- 835. Electronic remittances. Describes payments transmitted, remittance advice, and Explanation of Benefits directly between provider and payer or via a financial institution used to process payments.

EDI Status, Inquiry, Response and Process Codes

• Queries and responses codes include:

  -- 270 and 271. Eligibility inquiry, response: Used to determine member and dependent benefits.

  -- 276 and 277. Health care claim status inquiry, response: Used to determine claim status.

  -- 278. Health care service review information: Used to transmit health care information necessary to review and report services results.

  EDI Process codes include

  -- 997. Functional acknowledgement transaction: Used to define and present electronically encoded records.

  -- NCPDP Telecommunications Standard version 5.1, Retail pharmacy claim: Used to submit individual pharmacy claims to insurers and payers by providers.

Level 1 and Level 2 Compliance

• Organizations engaged in partner transaction testing complete Level 1 compliance for adoption of transaction set rules in 2010. Level 2 compliance, enabling transmission of standard data records between partners, follows in 2011.