The Health Insurance Portability and Accountability Act

HIPAA REGULATIONS: TRANSACTIONS AND CODE SETS

The original Transaction and Code Set regulation compliance date was October 16, 2002. However, recent legislation allows covered entities to delay the effective date until October 16, 2003 provided they submit a compliance plan to the Secretary of DHHS prior to the original due date (October 16, 2002). The compliance plan must demonstrate an entity's plan to pilot electronic transactions by April 2003.

The EDI Transaction and Code Set standards only cover transactions that are sent digitally and do not apply to paper transactions. Electronic transmissions include those conducted over the Internet, dial-up or leased lines as well as via private networks. Furthermore, these standards cover transactions that occur, or are transported, via magnetic tape, disk or CD media; although, telephone and fax responses are not currently included. There are presently more than 400 EDI formats in use by various payors. The new transaction and code set regulations will standardize both financial and administrative transactions, as well as the data elements required to conduct these electronic transactions. The following healthcare transaction standards have been specified in the HIPAA regulations:

ASC X12N 837	Health claims or equivalent encounter information
ASC X12N 835	Payment and remittance advice
ASC X12N 276/277	Claim status request and response
ASC X12N 834	Enrollment and disenrollment in a health plan
ASC X12N 270/271	Eligibility benefit inquiry and response
ASC X12N 820/811	Premium payment order/remittance advice
ASC X12N 278	Referral certification and authorization
ASC X12N 275	Patient information/attachments (No compliance date set)
ASC X12N 148	First report of injury (No compliance date set)

HIPAA mandates that covered entities transmitting electronically, adopt the standard transaction formats and their implementation guidelines. However, HIPAA does not require covered entities to convert from paper to electronic transactions. Nor does it mandate that providers submit these electronic transactions directly to payors. Providers can use, or continue to use a clearinghouse to format transactional data into the compliant format. Whether a provider transmits directly or uses a clearinghouse to interface with payors, it is critical for providers to understand that the new transaction formats may require additional data elements, not previously collected. Therefore, providers must be aware of the data format requirements in order to send only the necessary information required to process the specified transaction.

Further information

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