Accreditation

Complying with HIPAA's transactions and code set rules

Accreditation Connection, April 1, 2003

Ambulatory centers are among the many covered health care providers that must comply with HIPAA's transactions and code sets rule. The rule applies to any organization that provides or receives payment for health care and transmits health information electronically.

This also includes any organizations that send paper claims to clearinghouses that are later processed electronically.

The transactions and code sets law also requires most providers that submit claims to Medicare to do so electronically by Oct. 16. Only very small providers or suppliers are exempt. For example, providers with fewer than 10 full-time equivalent (FTEs) employees and suppliers with fewer than 25 FTEs may send paper claims directly to Medicare. If the small providers and suppliers choose to file claims electronically, they become covered providers and must follow the rule.

Covered providers have the following options for adopting the transactions:

  • Direct transmission is the ultimate goal of HIPAA. In this approach, providers and payers exchange transactions directly. To accomplish this, providers and payers need the proper information systems, which include a translator and communications technology, to conduct electronic data interchange (EDI).

  • Using a clearinghouse with the standard transactions is another option. This might include a mix of direct transmission as well as using a clearinghouse.

    Typically, if you send claims in several different ways, you send claims directly to Medicare (and possibly Medicaid), Blue Cross/Blue Shield, and a few major commercial payers. You would use a clearinghouse to send claims to other payers. This is useful if the other payers do not have the electronic capability to establish all the necessary connections.

  • Using a clearinghouse to format standard content is another option. This is useful for centers whose vendors do not supply translation software. A clearinghouse puts the data into a standard format. Clearinghouses cannot create or modify data content, so you must send all of the content that must be changed to the clearinghouse for formatting.

  • Direct data entry is something you can use if your payers offer it. Direct data entry allows employees to enter the data HIPAA requires for claims submission or eligibility inquiries using a Web-based form. Although the data must meet the HIPAA standards requirements, they do not have to be formatted into an X12N transaction for transmission. There are advantages and disadvantages to direct data entry-both on the provider side, relative to work flow and operations, and on the payer side

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