Transaction and Code Set Standards
The HIPAA Electronic Transactions (EDI) Standard
Electronic data interchange (EDI) is the electronic transfer of information, such as electronic media health claims, in a standard format between trading partners. HIPAA's Electronic Transactions Standard (the "EDI Standard") contains standards for eight (8) electronic transactions and for code sets to be used in those transactions. It also contains requirements concerning the use of the standards by health plans, healthcare clearinghouses, and healthcare providers. The HIPAA standard EDI format requires standardization of the data content by specifying uniform definitions of the data elements that are exchanged in each type of EDI transaction. The standardization is implemented to increase the efficiency of EDI and decrease costs to healthcare providers and health plans. In December 2001, Congress adopted legislation that allows most covered entities to obtain a one-year extension to comply with the standards, from October 16, 2002, to October 16, 2003. To qualify for the extension, the covered entity must submit a plan for achieving compliance by the new deadline. The plan must be submitted to HHS prior to October 16, 2002. Purdue submitted its request for extension on October 6, 2002.
Scope of Coverage
The EDI Standard applies to all health plans, all healthcare clearinghouses, and to any healthcare provider that transmits health information in electronic form in connection with any of the eight (8) transactions. Electronic transmissions include transactions using all forms of electronic media, even when the information is physically moved from one location to another using magnetic tape, disk or compact disc. Transmissions over the Internet (wide-open), Extranet (using Internet technology to link a business with information only accessible to collaborating parties), leased lines, dial-up lines, and private networks are all included. Telephone voice response and "faxback systems" (a system by which a request for information is made via voice using a fax machine and requested information returned via that same machine as a fax) would not be included.
Basic Rule
If a covered entity conducts a transaction for which a standard has been adopted, then the entity must conduct the transaction as a "standard transaction" (i.e. it must comply with the adopted standard). The entity may satisfy the rule either internally or through the use of a business associate, such as a healthcare clearinghouse. If a business associate is used, then the entity must have in place a business associate agreement requiring the business associate (and any of its agents or subcontractors) to comply with the EDI Standard.
Special Rules for Health Plans
Health plans must recognize standard transactions, even if the transaction contains data elements not needed or used by the health plan. The health plan may not delay or reject the transaction because it does not recognize a standard transaction. The health plan may not charge costs or fees in excess of normal telecommunications costs for using a healthcare clearinghouse to process transactions.
Code Sets
A code set refers to any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. HIPAA's EDI Standard contemplates the following code sets.
International Classification of Diseases, 9th Edition, Clinical Modification, (ICD-9- CM), Volumes 1 and 2 (including The Official ICD-9-CM Guidelines for Coding and Reporting), as maintained and distributed by HHS, for: (1) Diseases; (2) Injuries; (3) Impairments; (4) Other health problems and their manifestations; and (5) Causes of injury, disease, impairment, or other health problems.
International Classification of Diseases, 9th Edition, Clinical Modification, Volume 3 Procedures (including The Official ICD-9-CM Guidelines for Coding and Reporting), as maintained and distributed by HHS, for the following procedures or other actions taken for diseases, injuries, and impairments on hospital inpatients reported by hospitals: (1) Prevention; (2) Diagnosis; (3) Treatment; and (4) Management.
National Drug Codes (NDC), as maintained and distributed by HHS, in collaboration with drug manufacturers, for the following: (1) drugs; and (2) biologics.
Code on Dental Procedures and Nomenclature, as maintained and distributed by the American Dental Association, for dental services.
The combination of Health Care Financing Administration Common Procedure Coding System (HCPCS), as maintained and distributed by HHS, and Current Procedural Terminology, Fourth Edition (CPT-4), as maintained and distributed by the American Medical Association, for physician services and other healthcare services. These services include, but are not limited to, the following: (1) physician services; (2) physical and occupational therapy services; (3) radiological services; (4) clinical laboratory tests; (5) other medical diagnostic procedures; (6) hearing and vision services; and (7) transportation services including ambulance.
The Health Care Financing Administration Common Procedure Coding System (HCPCS), as maintained and distributed by HHS, for all other substances, equipment, supplies, or other items used in healthcare services. These items include, but are not limited to, the following: (1) medical supplies; (2) orthotic and prosthetic devices; and (3) durable medical equipment.
HIPAA's Eight (8) Standard Transactions
| Definition | A request to obtain payment, and the necessary accompanying information from a healthcare provider to a health plan for healthcare. |
| Standards |
Retail pharmacy drug claims. The National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Implementation Guide, Version 5 Release 1, September 1999, and equivalent NCPDP Batch Standard Batch Implementation Guide, Version 1 Release 0, February 1, 1996. Dental Health Care Claims. The ASC X12N 837 - Health Care Claim: Dental, Version 4010, May 2000, Washington Publishing Company, 004010X097. Professional Health Care Claims. The ASC X12N 837 - Health Care Claim: Professional, Volumes 1 and 2, Version 4010, May 2000, Washington Publishing Company, 004010X098. Institutional Health Care Claims. The ASC X12N 837 - Health Care Claim: Institutional, Volumes 1 and 2, Version 4010, May 2000, Washington Publishing Company, 004010X096. |
| Definition | The transmission of subscriber enrollment information to a health plan to establish or terminate insurance coverage. |
| Standards |
The ASC X12N 834 - Benefit Enrollment and Maintenance, Version 4010, May 2000, Washington Publishing Company, 004010X095. |
| Definition | An inquiry from a healthcare provider to a health plan, or from one health plan to another, to obtain eligibility, coverage or benefit information under the health plan and the health plan's response to the healthcare provider's inquiry. |
| Standards |
Dental, professional, and institutional. The ASC X12N 270/271- Health Care Eligibility Benefit Inquiry and Response, Version 4010, May 2000, Washington Publishing Company, 004010X092. |
| Definition | The transmission of payment, information about the transfer of funds, or payment processing information from a health plan to a healthcare provider's financial institution; or, the transmission of explanation of benefits (EOBs) or remittance advice from a health plan to a healthcare provider. |
| Standards |
Retail pharmacy drug claims and remittance advice.The NCPDP Telecommunication Standard Implementation Guide, Version 5 Release 1, September 1999, and equivalent NCPDP Batch Standard Batch Implementation Guide, Version 1 Release 0, February 1, 1996. Dental, professional, and institutional healthcare claims and remittance advice.The ASC X12N 835 - Health Care Claim Payment/Advice, Version 4010, May 2000, Washington Publishing Company, 004010X091. |
| Definition | The transmission of payment, information about the transfer of funds, or detailed remittance information about individuals for whom premiums are being paid or payment processing information (including payroll deductions, other group premium payments and associated group premium payment information) from the entity that is arranging for the provision of healthcare or is providing healthcare coverage payments for an individual to a health plan. |
| Standards |
The ASC X12N 820 - Payroll Deducted and Other Group Premium Payment for Insurance Products, Version 4010, May 2000, Washington Publishing Company, 004010X061. |
| Definition | The transmission of either an inquiry to determine the status of a healthcare claim or a response about the status of a healthcare claim. |
| Standards |
The ASC X12N 276/277 Health Care Claim Status Request and Response, Version 4010, May 2000, Washington Publishing Company, 004010X093 |
| Definition | Any of the following transmissions: (1) a request for the review of healthcare to obtain an authorization for the healthcare; (2) a request to obtain authorization for referring an individual to another healthcare provider; or (3) a response to a request of either (1) or (2). |
| Standards |
The ASC X12N 278 - Health Care Services Review--Request for Review and Response, Version 4010, May 2000, Washington Publishing Company, 004010X094. |
| Definition | The transmission of claims or payment information from any entity to a health plan for the purpose of determining the relative payment responsibilities of the health plan. |
| Standards |
Retail pharmacy drug claims. The NCPDP Telecommunication Standard Implementation Guide, Version 5 Release 1, September 1999, and equivalent NCPDP Batch Standard Batch Implementation Guide, Version 1 Release 0, February 1, 1996. Dental claims. The ASC X12N 837 - Health Care Claim: Dental, Version 4010, May 2000, Washington Publishing Company, 004010X097. Professional healthcare claims. The ASC X12N 837 - Health Care Claim: Professional, Volumes 1 and 2, Version 4010, May 2000, Washington Publishing Company, 004010X098. Institutional healthcare claims. The ASC X12N 837 - Health Care Claim: Institutional, Volumes 1 and 2, Version 4010, May 2000, Washington Publishing Company, 004010X096. |
These rules were modified in February 2003, and the new modifications should be analyzed for implementation prior to the compliance date. The compliance date remains unchanged (October 16, 2003).