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Electronic Transactions and Code Sets


The HIPAA Transactions deadline passed on October 16, 2003. As you may have heard, however, a number of industry participants, including CMS, have missed the deadline and are now busy trying to finish their compliance efforts.

Some of you may have purchased software updates, and others may have received information from your vendor(s) about changes required for October 16. Others may not have heard from their vendors, or are unsure of the requirements.

HIPAA Train Wreck

If you find yourself behind and uncertain about what to do, you’re not alone. Many covered entities (especially large organizations like health plans) underestimated the amount of work required for compliance and find themselves in a last minute crunch. Since CMS has not backed off on the October 16 requirement (given that they already extended by a year), some have called this the HIPAA Train Wreck. In recognition of this situation, however, CMS has released a guidance document to communicate how they will deal with noncompliance after October 16. Basically, they will evaluate if you have made an earnest effort to comply, and what you are doing to bring yourself within compliance. It’s important to document what you have done and are doing.

More recently, CMS released new guidance for those of you submitting Medicare claims. In July 2004, they will institute a new claims payment schedule for HIPAA compliant and non-compliant claims: HIPAA compliant claims will be paid no earlier that 14 days after receipt, and non-compliant claims will be paid no earlier than 27 days after receipt. A related article can be found here, and the document sent by CMS to carriers and fiscal intermediaries can be found here. What does this mean to providers and health plans who have not yet finished work on their TCS compliance? Basically, covered entities will be under aditional pressure to finish their compliance work as soon as possible.

HIPAA Transactions and Code Sets regulations

The federal regulations and the implementation guides have been revised. You can find the revised regulations here, as well as the original documents.

HIPAA Transactions and Code Sets requirements

All health plans, clearinghouses, and healthcare providers who submit transactions electronically must comply with HIPAA Transactions requirements. This includes using (faxing or sending your claims to) a billing service which converts your claims and then sends them to the insurance company; this is referred to as submitting through a clearinghouse.

• Transactions must be compliant with technology standards
• Business Associate agreements must be signed
• Local codes must be eliminated
• Compliance must be documented
• Staff must be trained

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