# Presentation: 831904

## What Every Provider Should Know about HIPAA Transactions

***Presented by Susan J. Fox***
***Fox Systems, Inc.***
- _[www.foxsys.com](http://www.foxsys.com/)_
***www.hipaaconsulting.com***
***susan.fox@foxsys.com***

## Topics

- Transaction Standards and Check List
- Code Set Standards and Check List
- Questions to ask Payers
- Questions to ask Vendors
- Other Questions
- Quiz: What does ’37’ mean to you?

## Treatment Providers’ Perspective

- Where Do You Fit in the Provider Landscape?
- Grant-funded only
- Medicaid biller only
- Paper biller only
- Both payer and provider
- Case manager
- Multi-payer
- Multi-state
- Some/ all electronic billing
- Changing from one status to another

## Treatment Providers’ Perspective

- What Is Your HIPAA Status?
- Your unique payer says it is not a covered entity
- Payer says it is covered but will not be ready
- Each payer gives you different instructions
- You Can’t Figure It Out!

## Covered Entity Quiz

- Are you a provider as defined in the law?
- Do you conduct any of the HIPAA transactions (e.g., claims, remittance advice, eligibility verification) electronically?
- Do you send and/or receive a covered transaction from even one payer who is a covered entity?
*3 x YES = You are a Covered Entity Provider!*

## Why Are StandardsImportant for You?

- Standard method for submitting claims
- Standard method for getting paid
- Use of transactions can greatly improve efficiency and reduce paperwork
- Real-time Eligibility/Benefits
- Penalties for non-compliance
- Non-compliance can result in a cash flow disruption or improper payment

- MN1*41*2*MARY SMITH CLEARINGHOUSE*****46*0003000
- PER*IC*MARY SMITH*TE*9135551234*FX*6123334567*ED*6125559876~
- NM!*40*2*MEDICARE PART B*****46* WHY INC~
- HL*1*20*1~
- MNI*85*2*EYEBALL SURGERY ASSOCIATES*****24*123456789~
- N3*PO BOX 1234~
- N$*SALISBURY*MO*660453565*US
- REF*1C*09876~
- PER*1C*BILLING PROVIDER CONTACT OFFICE NURSE*TE*9135551234*FX*
- 6123334567TE* 6125559876~
- HL*2*1*22*0~

***What Your Computer Sees***
***During an 837 Transaction***

## X12 Overview

- NM1***IL*1*SMITH***TED****34*000221111

## Check List - Transactions

- Identify which HIPAA transactions you use: claim, remittance advice, eligibility inquiry, claim status request, prior authorization
- Will you be conducting any of these electronically?
- Prioritize implementation based on risk and benefit analysis for your practice
- Identify required data elements not used by your vendor system

## Code Sets Standards	

_**Today**_
- Providers maintain multiple code sets (including local codes) to meet different payer requirements
_**With HIPAA**_
- No local codes; Standard codes for all payers
- Only standard code sets can be transmitted in the mandated transactions
- Codes are **medical/clinical** **or** **non-medical**
- External and internal Code Sets (to the*** Implementation Guides)***

## HIPAA Medical Codes

- International Classification of Diseases Covenant Provision, Clinical Modification (ICD-9-CM)
- Current Procedural Terminology (CPT)
- Healthcare Common Procedure Coding System (HCPCS)
- National Drug Codes (NDC)
- 	*Alcohol and Other Drug (AOD) Procedure, Behavioral Health Procedure and Modifier Codes must be mapped to HIPAA codes or obtain approval for requested codes*

## HIPAA Non-medical Codes

- Place of Service
- Type of Bill
- Postal codes
- Claims Status
- Admission Type
- Languages

- Country Codes
- Claim Adjustment Reason
- Patient Status
- Remittance Remark Codes
- DRGs
- Revenue Codes

## Check List - Code Sets

- Identify which codes you use
- Identify codes that are not HIPAA approved
- What new codes are needed to replace non-compliant codes
- Educate employees about all coding changes (screens, reports)
- Identify which of the provider taxonomy codes apply to your providers

## Business Associates
An individual or organization that performs a function on behalf of the covered entity, involving the use or disclosure of Protected Health Information. 
 A billing service who processes claims for a provider

Trading Partners
An organization with whom a covered entity exchanges information electronically using a named transaction standard
 A provider and a payer are trading partners

- An individual or organization that performs a function on behalf of the covered entity, _involving the use or disclosure of Protected Health Information__._
-  *A billing service who processes claims for a provider*
**Trading Partners**
- An organization with whom a covered entity exchanges information electronically using a named transaction standard
-  *A provider and a payer are trading partners*

- Business Associates & Trading Partners

**Notes:**
A business associate is an individual or organization that:
Performs, or assists in the performance of, a function or activity on behalf of the covered entity, involving the use or disclosure of PHI  (such as claims processing or administration, data analysis, utilization review, quality assurance, billing, practice management, etc.); or
Provides legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services to or for a covered entity
e.g.:  A covered health care provider uses a clearinghouse to submit and receive transactions; the clearinghouse needs to use and disclose PHI in order to perform its functions.  The clearinghouse is a business associate of the provider
A covered entity may be a business associate of another covered entity
Clinical/case management services offered by a provider to a covered entity requires a BA relationship
May be covered entities themselves
Trading Partners are:
An organization with whom a covered entity exchanges information electronically using a named transaction standard
A health plan and a provider are trading partners
A provider and a clearinghouse are trading partners
Usually a trading partner agreement is established between the two entities
If requested, a health plan MUST conduct a transaction as a standard transaction (one that complies with HIPAA standards) if the health plan performs that business function
Health plans cannot delay or reject standard transactions 
Some health plans may require providers to conduct transactions electronically. 
No extra fees can be charged beyond transmission costs

## Check List - Trading Partners

- Identify key trading partners (payers)
- Evaluate the flow of your data to/from your trading partners
- Learn about their plans for compliance
-  Examine trading partner agreements and companion documents

## Check List - Trading Partners

- Identify how your payers will confirm that your transactions are successful
- Find out how your payers will assure the privacy and security of the transactions you send them
- Determine the level of testing that has been conducted by each payer

## Check List - Trading Partners

- Identify a process to verify that the payers follow HIPAA compliance rules consistently
- Request copies of code conversions used by the payers (you send HIPAA codes; they convert to non-standard)

## Web and Direct Data Entry Transactions

- Trend to web-enable large payer systems for transaction submission
- All web and direct data entry systems must meet the HIPAA transaction standard for data content

**Notes:**
Trend to web-enable large payer systems for transaction submission

All web and direct data entry systems must at least meet the data content portion of the respective HIPAA transaction standard

## Check List - Billing/Practice Management Vendors

- Determine which of the transactions your system can send and/or receive
- Which payers has the vendor tested with and what tests have been performed?
- Confirm that your system supports the collection of all new required and situational elements

## Check List - Billing/PM Vendors

- Confirm that your system has controls to prevent the entry of non-compliant values
- Has your system’s look-up fields for codes and other values been updated to current HIPAA required code standards
- Find out the maintenance and update schedule for all codes sets and versions
- Identify the type of security your system uses to transmit and receive transactions

## Check List - Billing/PM Vendors

- Identify how your system will post and reconcile  outgoing and incoming transactions
- Assure that your system is receiving the claim and line item identifiers in your 835 or remittance advice
- Confirm that all the lines that were sent return with the (electronic) remittance advice

## Check List - Certification

- Solicitations for Compliance Testing and Certification
- Ask your payers and system vendors if they have obtained compliance certification
- There is no certification for the certifiers
- Testing before “going live” saves money
- Certification by an industry accepted testing source provides more assurance that your billing service can meet the standards and it documents your compliance status

## Check List - Other

- Will your payer send money directly to your bank?
- Do you have a contingency plan for failure to meet deadline?
- Identify any charges that may be associated with clearing house functions and your responsibility for those charges

## CMS HIPAA Information Series on Electronic Transactions

- 	HIPAA 101;  Are you a covered entity?
- What electronic transactions and code sets are standardized under HIPAA?
-  Is your software vendor or billing service ready?
-  What you need to know about testing
-  Trading Partner Agreements;  Enforcement

- Series can be found on the CMS website at: http://www.cms.hhs.gov/hipaa/hipaa2/education/infoserie/.  Series also available in Spanish.