The Health Insurance Portability and Accountability Act (HIPAA Public Law 104-191) was signed into law in 1996 to provide better portability and accountability. Administrative Simplification standards and resulting rules will have a significant impact on you and health care organizations. As required by Congress in HIPAA, the standards cover health plans, health care clearinghouses, and those health care providers who conduct certain financial and administrative transactions electronically.
Compliance with HIPAA Standards for Electronic Transactions is required by October 16, 2002 or October 16, 2003 if you have filed for an extension. You can consult the US Department of Health and Human Services for more information concerning the EDI and other requirements related to HIPAA.
The Administrative Simplification provisions cover:
- Electronic Transactions
- Security
- Privacy
- Unique Identifiers
- Code Sets
Listed below are the mandatory Transaction Standards and codes sets as outlined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- ASC X12N 837-Health Care Claim: Dental
- ASC X12N 837-Health Care Claim: Professional
- ASC X12N 837-Health Care Claim: Institutional
- ASC X12N 270/271-Health Care Eligibility Benefit Inquiry and Response
- ASC X12N 278-Health Care Services Review / Request for Review and Response
- ASC X12N 276/277 Health Care Claim Status Request and Response
- ASC X12N 834-Benefit Enrollment and Maintenance
- ASC X12N 835-Health Care Claim Payment/Advice
- ASC X12N 820-Payroll Deducted and Other Group Premium Payment for Insurance Products
X12 Standards are required for all HIPAA transactions except for pharmacy claims. In that case, standards developed by the National Council for Prescription Drug Programs (NCPDP) have been adopted.
eEDI currently utilizes HIPAADesk from EDIFECS Corp for compliance testing. The above transaction sets are sent to them for testing purposes. Once a transaction set is sent to HIPAADesk they will verify the following as compared to the standards established pursuant to HIPAA.
All transactions sent to HIPAADesk are tested for:
- Integrity Testing (X12 Syntax)
- Requirement Testing (Implementation Guide Syntax)
- Balancing
- Situation Testing (Implementation Guide "Situational Elements")
- Code Set Testing
- Specialty or Line of Business Testing
- Trading Partner Specific Testing
Once HIPAADesk receives the Data and verifies the above criteria it will be deemed “Certified”. Certifications enable trading partners to simply and easily determine what to expect from one another, on both ends of every transaction, thus eliminating the need for prolonged and costly troubleshooting. Our company philosophy is such that by having an outside party test and certify our transactions and compare them to the rules set forth by HIPAA then all companies we contract with will need to adhere to our standards and company policies. By maintaining this philosophy eEDI will be insuring transactions meet all necessary government standards as well as reducing the implementation time required to make sure that each transaction is sent and received in a timely fashion.
