HIPAA Transactions: A Non-Technical Business Guide for Health Care

by American Medical Association

• ISBN13: 9781579475574
• ISBN10: 1579475574
• Edition: 1st
• Format: Nonspecific Binding
• Copyright: 2003-12-30
• Publisher: AMERICAN MEDICAL ASSOCIATION

Summary

This resource begins with a synopsis of administrative simplification and a quick overview of the HIPAA transactions standards. It examines the eight types of transactions standards, defines electronic terms, and explores the pros and cons of alternative electronic transactions methods. Also included is information on code sets and implementation guides plus return-on-investment analyses that build a statutory, business and regulatory case for adopting the transaction standards. It also addresses the future of transaction standards, including claims attachments, electronic medical records and electronic prescriptions, and future trends in transaction processing.

Table of Contents

Dedication	ii
Foreword	iii
Acknowledgments	v
About the Authors	vii
How to Use This Book	ix
Introduction	xv
Achieving Success with Transactions	1	(14)
The Big Picture of HIPAA Transactions	2	(1)
The Nuts and Bolts of Administrative Simplification	3	(4)
Building the Infrastructure	5	(1)
Four Sets of Standards	5	(2)
The HIPAA Transactions Rule	7	(1)
The Claims Process: Paper and Electronic Environments	7	(6)
Benefits of HIPAA Transactions and Code Sets	13	(1)
Summary	14	(1)
The Business of HIPAA Transactions	15	(20)
The HIPAA-Compliant Transaction	17	(2)
Types of HIPAA Transactions and What They Mean	19	(1)
Planning for HIPAA Transactions	19	(7)
Building the Implementation and Compliance Plan	19	(7)
The Certification and Testing Process	26	(3)
What You Should Know About Testing	27	(2)
What You Should Know About Certification	29	(1)
Business Challenges	29	(4)
Billing Cycles	30	(1)
Staff Acceptance	30	(1)
Implementation Guides	30	(1)
Trading Partner Agreements	30	(1)
Health Plan-Specific Information	31	(1)
Payer Companion Guides	32	(1)
Enforcement	33	(1)
Enforcement Will Be Complaint-Driven	33	(1)
Covered Entities Can Submit a Corrective Action Plan or Demonstrate Compliance	34	(1)
More HIPAA Transactions to Come	34	(1)
A Case Study Through HIPAA Transactions	35	(24)
Case Study	36	(1)
Eligibility Inquiry (The 270)	36	(2)
What the 270 Will Do For You	36	(1)
Challenges	36	(2)
Eligibility Response (The 271)	38	(2)
What the 271 Will Do For You	39	(1)
Challenges	39	(1)
Level 1 Response	39	(1)
Level 2 Response	39	(1)
Level 3 Inquiry	39	(1)
Inquiry Errors	39	(1)
Health Care Claims/Encounters (The 837)	40	(1)
What the 837 Will Do For You	40	(1)
Challenges	40	(1)
How to Use the 837P	41	(6)
Section 1: Billing/Pay-to Provider Information	42	(1)
Section 2: Information About the Patient and Payer	42	(2)
Section 3: Claim Information	44	(2)
Section 4: Service Line Information	46	(1)
Remittance Advice (Claim Payment) Transaction (The 835)	47	(4)
What the 835 Will Do For You	48	(1)
Challenges	48	(1)
Transaction Summary	48	(3)
Corrections or Reversals	51	(1)
Claim Status Transactions (The 276)	51	(2)
What the 276 Will Do For You	52	(1)
Challenges	52	(1)
Information You'll Need for a Claims Status Inquiry	52	(1)
Service Line Information	53	(1)
Claim Status Response (The 277)	53	(1)
Category Codes	53	(1)
Status Codes	53	(1)
Entity Codes	53	(1)
Authorization/Referrals (The 278)	54	(3)
What the 278 Will Do For You	55	(1)
Challenges	55	(1)
Request	55	(2)
Response	57	(1)
HIPAA Transactions Summary	57	(2)
The Importance of Code Sets	59	(12)
An Overview of Code Sets	59	(1)
Code Sets in the Physician's Office	60	(1)
Code Set Categories	61	(3)
Medical Data Code Sets	61	(2)
Nonmedical Data Code Sets	63	(1)
How to Read Code Sets	64	(7)
External Code Sets	64	(4)
Internal Code Sets	68	(3)
Implementation Guides Primer	71	(20)
Transaction Standards Revisited	72	(2)
Structure of the Implementation Guides and Addenda	74	(4)
First Things First	78	(2)
Trading Partner Agreements	78	(1)
Required vs Situational Data Elements	78	(1)
Batch vs Real Time Transactions	79	(1)
Loops	79	(1)
Transaction Set	80	(1)
Data Segment	80	(1)
Data Element	80	(1)
Structure of the ASC X12N Standard Transaction	80	(1)
Control Segment Structure	81	(1)
Transaction Sets	82	(2)
The 270 Eligibility Benefit Inquiry Transaction Set	84	(3)
Example of an Eligibility Inquiry	87	(4)
Cost, Price, Value, and Return on Investment	91	(16)
Financial Assessment Tools	91	(1)
You and Your Electronic Investment	92	(1)
A Little Subjective History	92	(2)
The 1960s	92	(1)
The 1970s	93	(1)
The 1980s	93	(1)
The 1990s	93	(1)
The 2000s	94	(1)
Implications of This Odyssey	94	(1)
Looking Ahead: An Uncertain Health Care Environment	94	(4)
Size and Complexity of US Health Care Market	95	(1)
Potential Market Disturbances: Paradigm Shifts	95	(3)
Reinventing Your Future	98	(1)
The Next Big Thing	99	(8)
Electronic Medical Record	100	(2)
Debit Card	102	(5)
Appendix	107	(24)
Helpful resources. . . .	107	(1)
Guidance on Compliance with HIPAA Transactions and Code Sets, July 24, 2003	108	(2)
Transcript from CMS HIPAA Roundtable, Sept. 25, 2003	110	(2)
Electronic Submission of Medicare Claims Interim Final Rule	112	(10)
Transactions and Code Sets Interim Final Rule, Medicare Program: Electronic Submission of Medicare Claims	122	(2)
Implementation of the Telecommunication or Batch Standard	124	(2)
Check for Understanding Self Test	126	(5)
Glossary	131	(4)
Index	135