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Be prepared for HIPAA transactions standards

HIM Connection, February 28, 2003

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HIPAA requires the adoption of standards for financial and administrative transactions. These transactions include:

• Health care claims or equivalent encounter information
• Health care payment and remittance advice (explanation of benefits)
• Coordination of benefits
• Health care claim status
• Enrollment and disenrollment in a health plan
• Eligibility for a health plan
• Health plan premium payments
• Referral certification and authorization
• First report of injury
• Health claims attachments

Health plans participate in all of these transactions. Providers submit claims, receive remittance advice, participate in coordination of benefits, request claim status information, perform eligibility verification, obtain referral certification, provide first report of injury, and file health claims attachments. Employers who provide health benefits and other sponsors of health plans use enrollment and premium payment transactions.

Current regulations require adoption of standards for all the transactions except first report of injury and claims attachments by health plans by October 16, 2003 (after having filed a compliance plan to obtain an extension from the original compliance deadline of October 16, 2002). Clearinghouses are also required to adopt the HIPAA standards. There are no regulations proposed yet for first report of injury and health claims attachments, but we do have some information about the claims attachment standards that are likely to be required. Employers are not covered entities under HIPAA, but may be required through contract with a health plan to adopt the enrollment and premium payment standards.

This week's HIM Connection was adapted from HIPAA Transactions Made Simple: Achieving the Benefits of EDI. This new book and companion CD-ROM provides a step-by-step plan to help your organization adopt the new HIPAA transaction standards. Regardless of the health care setting you work in, HIPAA Transactions Made Simple offers a chapter-by-chapter process for transactions implementation. For more information or to order your copy, click here.

Sincerely,

Kim Raines
Managing Editor

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