HIPAA - Standards for Electronic Transactions 

As prepared by Dunlap & McDowell for 2/28/03 Pragmatics of HIPAA Training

Here is a link to the Federal Register: February 20, 2003 (Volume 68, Number 34)] [Rules and Regulations] [Page 8381-8399]  which gives the current version version of the  final rule in text form.

Here is a link to the same final transactions rule in .pdf (Adobe Acrobat) format

Mental Health Professionals:

Under HIPAA Transaction standards mental health professionals will be required to use HIPAA standard diagnosis and procedure codes, which are ICD rather than DSM. 

All electronic transactions regulated by HIPAA must be in the American National Standard’s Institute’s Accredited Standards Committee format. 

Information about those requirements and their implementation can be obtained from Washington Publishing Company, PMB 161, 5284 Randolph Road, Rockville, MD, 20852-2116 and on line at http://www.wpc-edi.com

 Standard Transactions and Code Sets.

Health plans must be capable of accepting all the required standard transaction submissions by October 16, 2003. 

Note: this date represents a 12-month delay. Covered entities who wanted additional time were to have submitted an extension request to the Department of Health and Human Services by October 16, 2002. Only about 20% of the expected number filed.  

If you are worrying because you didn't file note the passage on p. 8384 Federal Register / Vol. 68, No. 34 / Thursday, February 20, 2003 / Rules and Regulations which says:  ... we recognize that the modifications adopted as a result of CMS–0003–P and CMS–0005–P are necessary to permit the transactions covered by these proposed rules to be conducted in standard form, and that such transactions could not feasibly be required before the compliance date for the modifications in this final rule, October 16, 2003. We will not invoke our authority to penalize noncompliance with standards that our own delay in issuing this final rule has made infeasible.

 A provider who submits claims electronically, and/or makes eligibility, benefit, claims status, and claims inquiries electronically, must transmit these transactions to the health plan in the American National Standards Institute Accredited Standards Committee standard (ANSI X12N) format. Each standard has a prescribed format and content for electronic transmission.

 Please see the text or .pdf versions of the rule, linked above, for the specific transactions requirements.

Health plans and healthcare clearinghouses have to be able to accept all ASC X12N standards formats and content. Providers and professionals have options.

Professionals billing electronically may rely on a clearinghouse to convert claims to standard format, and to add required data content.

A clearinghouse would re-format the transactions and then submit to the respective health plan. Providers and professionals may choose to send standard content to health plans through the Internet (if the health plan is set up for this); this is called direct data entry. Finally, providers and professionals may be able to adopt the standard format themselves and submit the standard content and format to the clearinghouse or health plan directly.