1. HIPAA Administrative Simplification Final Rule for Transactions Code Sets Stanley Nachimson CMSsnachimson@cms.hhs.gov

2. Transaction Standards Final Rule n Authority - HIPAA, 1996 Title II n Rule Published August 17, 2000 n Applies to covered entities: u Health plans u Health care clearinghouses u Health care provider who transmits electronic transactions.

3. Provisions of the Rule n Covered entities must comply by Oct 16, 2002 (except small plans - Oct 16, 2003) n DSMOs maintain standards n Process for new standards or modifications u Request to DSMOs u Recommendation to NCVHS u Rulemaking

4. Provisions of the Rule n Trading Partner agreements cannot change the standards. n Covered entities conducting transactions with each other (or within themselves) must use the standards. n Direct data entry must meet content, not format. n Covered entities can use business associates to conduct transactions.

5. Provisions of the Rule (Health Plans) n If requested by any entity, a health plan must conduct a transaction as a standard transaction. n Health plans cannot delay transactions because they are standard n Health plans cannot reject standard transactions because they contain data elements not used by the plan.

6. Provisions of the Rule (Health Plans) n Health plans cannot offer incentives for direct data entry. n Health plans operating as clearinghouses or requiring the use of a clearinghouse cannot charge extra fees beyond normal transmission costs. n COB data must be stored. n Use the standard code sets and keep current.

7. Provisions of the Rule (Health Care Clearinghouses) n As a business associate, a clearinghouse can: u Receive a standard transaction and translate it into a non-standard transaction. u Receive a non-standard transaction and translate it into a standard transaction.

8. Provisions of the Rule n An exception may be granted to test a proposed modification to the standard u Request made to the Secretary u Test must be conducted u Report on test results made

9. Standards Adopted n Transactions: u Claims: F Retail pharmacy drug claims - NCPDP Telecommunications 5.1, Batch 1.0 F Professional, Dental, Institutional - X12N 837 4010 Implementation Guides

10. Standards Adopted n Eligibility Inquiry and Response u Retail Pharmacy - NCPDP Telecommunications 5.1, Batch 1.0 u Dental, professional, institutional - X12N 270/271 4010 Implementation Guide

11. Standards Adopted n Referral Certification and authorization u Retail pharmacy - NCPDP u Professional, Dental, Institutional - X12N 278 4010 Implementation Guide n Claims status inquiry and response u X12N 276/277 4010 Implementation Guide

12. Standards Adopted n Enrollment and Disenrollment in a Health Plan u X12N 834 4010 Implementation Guide n Payment and Remittance Advice u X12N 835 4010 Implementation Guide

13. Standards Adopted n Health Plan Premium Payments u X12N 820 4010 Implementation Guide n Coordination of Benefits u Retail pharmacy drug claims - NCPDP Telecommunications 5.1, Batch 1.0 u Dental, professional, institutional claims - X12N 837 4010 Implementation Guides

14. Code Sets Adopted n Diagnoses and inpatient hospital services - ICD-9-CM n Drugs, biologics - NDC codes n Dental services - CDT n Physician and all other services - CPT- 4/HCPCS

15. Implementation Considerations n Accepting and sending transactions - translator, clearinghouse, system change n Changes in data content in standard transactions - gap analysis n Alignment with paper processes n Elimination of local codes n Coordination among plans and payer - SNIP

16. Medicare Actions n Detailed Instructions to Contractors n Minimize impact on internal processing n Provider testing to begin by Jan 2, 2002

17. Other Rules for HIPAA Standards n Privacy n Security n NPI n Employer ID n Attachments, Plan ID, Enforcement.

18. Important Web Sites n DHHS Administrative Simplification - u FAQs, submit questions u aspe.hhs.gov/admnsimp n Implementation Guides u www.wpc-edi.com/hipaa n Implementation - SNIP at WEDI u www.wedi.org n Standards Change Requests u www.hipaa-dsmo.org