HIPAAnotes Volume One, November 2001

No. 54 HIPAA terms -- FYI: DSMOs, TPTB in TCS (Translation -- For Your Information: Designated Standard Maintenance Organizations, The Powers That Be in Transactions and Code Sets)

For many, understanding HIPAA Transactions and Code Sets requires struggling though a jungle of acronyms. But, once you decipher a few acronyms, the rest start making a lot more sense. It’s no different, really, than when purchasing a vehicle: once you’ve checked out RVs and SUVs, identifying an ATV is almost a no-brainer. Well…almost.

In the world of EDI (electronic data interchange), transaction formatting and coding must be standardized to enable fast and easy electronic communication. HIPAA required DHHS to consult with DCCs (Data Content Committees)and SSOs(Standard Setting Organizations) before adopting new standards. HIPAA also required that DSMOs (Designated Standard Maintenance Organizations) be designated to maintain the standards. Six DCCs and SSOs have agreed to be DSMOs:

• ASCX12 (easy – that’s Accredited Standards Committee X12), key in the development and maintenance of HIPAA’s X12 standards relating to health plans, including private health insurance and government programs such as Medicaid and Medicare.
  
  
• HL7 (Health Level Seven) develops specifications for messaging applications (such as interfaces) which allow disparate healthcare applications to exchange clinical, financial and administrative data.
  
  
• NCPDP (National Council for Prescription Drug Programs), a group that includes payers, retail and institutional pharmacies and government agencies. Its HIPAA job is to advise ASCX12 on developing standards as they apply to the pharmacy industry.
  
  
• NUBC (National Uniform Billing Committee), brought together by the AHA and includes provider and payer members. The NUBC was formed to develop one billing form and standard data set to be used for institutional health claims. The data set is also used by public health and researchers.
  
  
• NUCC (National Uniform Claim Committee), chaired by the AMA and HCFA, developed a standardized data set for the non-institutional health care community to transmit claim and encounter information to and from payers.
  
  
• DeCC (Dental Content Committee of the American Dental Association), a non-profit data content organization that evaluates proposed changes and their effects on dental providers.

FAQs regarding transactions.

No. 53 HIPAAregs: Will the HIPAA EDI Standards Change?

In a word, YES.

The HIPAA transactions standardization process is an ongoing one, if only because of the heterogeneous nature of healthcare organizations and processes. For example, once the final Transactions Rule was published, some providers conducting gap assessments found that they could not implement some standards exactly as written because certain data needed to populate the records was not available.

HIPAA prepared for this eventuality with EDI by authorizing DHHS to accept and evaluate industry requests for changes to the EDI standards, and to modify a standard (or its implementation guide specifications) one year after it has been adopted, but not more than every 12 months. HHS is authorized to set implementation dates, but not earlier than 180 days after adoption of the modification.

A web site at http://www.hipaa-dsmo.org has been established to enable healthcare industry members to request changes in standards. Designated Standards Maintenance Organizations (DSMOs) have developed a procedure for quickly reviewing each request, recommending action, and coming to consensus on final actions, in order to ensure successful industry-wide implementation of the standards.

So, while specific standards have already been adopted, to work properly they may have to change. We have already been told by DHHS to expect the first proposed modifications of the HIPAA transaction standards in December. The modifications will include limiting the use of National Drug Codes to retail pharmacies.

To learn more about DSMOs, tune in to next week's HIPAAnote!

No. 51 HIPAAregs: EDI Transactions: The Countdown Continues

Less than 12 months remain before the HIPAA Transactions and Code Sets
compliance deadline! Though we’ve already passed the midpoint of the compliance period, many covered entities remain unaware of the hurdles that EDI standardization will present for their operations. For those who have just joined the race here is a quick outline of the Rule’s specifics:

Proposed rule published: May 7, 1998
Final rule published: August 17, 2000
Compliance date: October 16, 2002 (one year later for small health plans)

The transactions under mandated standardization are:

• X12N 837 -- Professional Healthcare claim or encounter
• X12N 837 -- Institutional Healthcare claim or encounter
• X12N 837 -- Dental Healthcare claim or encounter
• X12N 835 -- Health Care Claim Payment/Remittance Advice
• X12N 270 -- Health Insurance Eligibility request verification for covered benefits
• X12N 271 -- Health Insurance Eligibility response verification for covered benefits
• X12N 834 -- Enrollment / Disenrollment to a health plan
• X12N 276 -- Health Care Claim, inquiry to request the status of a health claim
• X12N 277 -- Health Care Claim, response to request the status of a health claim
• X12N 278 -- Health Care Services, to request authorizations and referrals
• X12N 820 -- Premium Payment, for enrolled health plan members

The code sets under mandated standardization are:

• ICD-9: International Classification of Diseases
• NDC and J-Codes -- National Drug Codes
• CDT-L -- Code on Dental Procedures and Nomenclatures
• HCPCS -- Health Care Financing Administration Common Procedure Coding System
• CPT-4 -- Current Procedural Terminology

More insight on compliance with the HIPAA mandated transactions.

No. 52 HIPAAregs: EDI Implementation: Moving Along the Compliance Timeline

With less than 12 months left to comply with the HIPAA Transactions and Codes Sets Rule, covered entities should be moving into their planning and implementation phases. Considering the work required in implementation, organizations’ initial impact and gap analysis should be complete, with implementation teams in place, and trading partner agreements fully reviewed and updated. If your organization isn’t this far along in the compliance process, it’s time to double-time it!

How will EDI transactions implementation affect your operations? Here are some questions to consider:

• Have you focused on how electronic availability of eligibility determination may change – or require changes – in your day-to-day operations?
  
  
• Does your compliance planning include developing policies and procedures relative to the upcoming changes in claims status and inquiries processing?
  
  
• Are there insurance, employer, provider and patient masters that will need to be cleaned up to ensure a clean conversion of the data?
  
  
• If you haven’t begun the process toward compliance, what are your contingency plans? Will you revert back to manual operations?

More insight on the impact of EDI Transactions on your operations.

The most updated FAQs posted by DHHS as of 9/17/01.