| Overview | CMS to Enforce HIPAA TCS Standards |
| Applicability | DMAS Companion Guides |
| Transaction Sets | Provider Links |
| Code Sets | Standards Links |
| Local Codes Crosswalk | Error Code Crosswalk |
Health care providers and health plans use varied formats when performing daily electronic transactions, which can be very confusing and difficult to coordinate. The Health Insurance Portability and Accountability Act of 1996, states that these entities must comply with Health Transaction rules to be implemented by October 17, 2002. In order to improve the efficiency and effectiveness of the healthcare system the American National Standards Institute has developed these specific electronic transaction formats which all health care plans and providers must integrate into their business activities. The implementation of standard electronic data interchange (EDI) formats for these transactions will reduce the burden of health care providers and billing services. Additional information on the background of these standards can be found at http://aspe.os.dhhs.gov/admnsimp/kkimpl.htm.
The Electronic Transactions Standard applies to all of the types of business that are performed daily to provide proper healthcare. These include:
Health claims, claim status, plan eligibility, enrollment and disenrollment, payments for care and premiums, coordination of benefits and other related transactions.
All health providers, clearinghouses and plans that will transmit health related information electronically.
Clearinghouse transmissions to providers and health plans, this also includes transmissions to and from other clearinghouses.
Transactions include transmissions which use all types of media including Internet, dial-up lines and private networks.
All health plans for all transactions. Those plans which conduct business through a contractor/agent must ensure that all applicable rules and regulations that are met.
Provider transmissions and the reception of electronic transmissions.
A summary of Electronic Transactions can be found at www.jhita.org/electric.htm.
The Accredited Standards Committee (ASC)X12 has developed nine (9) electronic formatting standards for the exchange of all types of health care business information. More information on this organization can be found at www.x12.org. The transactions sets are as follows:
|
Health care or equivalent
encounter information |
|
Enrollment and
disenrollment in a health plan |
|
Eligibility for a health plan |
|
Claim Payment |
|
Health claim status |
|
Referral certification and
authorization Payroll Deducted/other group premiums (820) |
HIPAA requires the standardization of the reporting of medical procedures with industry established and maintained codes. These are the codes used by the health care providers to identify what procedures, services and diagnoses pertain to that encounter. This will eliminate the use of government and commercial proprietary medical codes sets. The codes sets that have been approved for use by HIPAA are:
|
International Classification of
Diseases, 9th Edition, Clinical Modification |
|
Common Procedural Terminology, 4th
Edition |
|
Health Care Finance
Administration Common Procedural Coding System |
|
National Drug Codes |
|
Current Dental Terminology |
Local Codes to National Codes Crosswalk
Please Note: This information supercedes any information related to HIPAA Transactions and Codes Sets included in previously
published DMAS Provider Manual Updates and Medicaid Memoranda.
Beginning January 1, 2004 DMAS will only accept HIPAA standard formatted electronic claims.
In addition, Virginia Local codes will be accepted in lieu of mandatory National Codes for claims with dates of service on or before December 31, 2003.
See Medicaid Memo dated
9/16/2003.
The Department of Medical Assistance Services (DMAS) previously notified providers about the new Medicaid Management Information System (MMIS), which was released June 26, 2003. DMAS' new MMIS system accepts either the Local or Na
The Department of Medical Assistance Services has established a crosswalk to assist the providers in determining the appropriate National Codes to use in replacing the Local Codes.
A
complete copy of the crosswalk, as of May 19, 2004, in PDF format can be viewed and printed here.
Please
use this crosswalk to assist you in identifying the error codes.
The Error Code crosswalk is valid for remittance advices as of July 3, 2003 and forward. The following
information is meant to assist you with understanding this crosswalk.
The ESC column is a numeric value assigned to the description listed.
The Description is a brief explanation associated for that ESC.
A listing of the HIPAA Claims Adjustment Reason Codes, Remittance Advice Remark Codes, and Claims
Status Codes can be found at the Washington Publishing Company Web Site,
http://www.wpc-edi.com/codes/Codes.asp
A PDF listing of the NCPDP Pharmacy Reject Codes can be found at
www.ctmedicalprogram.com/edi_specs/ncpdp_reject.pdf
CMS to Enforce HIPAA TCS Standards
October 15, 2002- HHS Secretary Tommy G. Thompson announced that the Center for Medicare and Medicaid will be reinforcing the HIPAA transaction and code sets standards. .
You can now use the Online Complaint Submission Form to submit complaints about covered entities who are not compliant with the HIPAA electronic transactions and code set standards.
DMAS Companion Guides
First Health Services Corporation is the fiscal agent for the State of Virginia, Department of Medical Assistance Services. First Health Services Corporation is providing Companion Guides to the HIPAA guidelines for the electronic transactions. For more information click:
http://virginia.fhsc.com/VA_CompanionGuide.asp
http://www.fhsc.com/hipaa/HIPAAmain.asp
Has First Health Services Corporation Update newsletter for FHSC clients and colleagues. Links to the HIPAA Final Rule for Transactions and Code Sets along with Corrections to the Final Rule for Electronic Transactions and Code Sets are provided as well.
http://www.nucc.org]
Has data set information for submission of claims and other health
care information
http://aspe.os.dhhs.gov/admnsimp/kkimpl.htm
U.S. Dept. of Health and Human Services Administrative
Simplification web site, includes press releases and FAQ’s
http://www.hipaa-dsmo.org/crs/
Enables providers to request revisions to the transaction
standards
http://aspe.hhs.gov/admnsimp/pl104191.htm
Details of Public Act 101-191 Health Insurance Portability and
Accountability Act of 1996
http://www.wedi.org/
Workshop for Electronic Data Interchange
http://hipaa.wpc-edi.com/HIPAA_40.asp
Washington Publishing Company, this company manages and
distributes Electronic Data Interchange (EDI) information.
www.hl7.org
Health Level Seven, this organization produces standards for
clinical and administrative data.