HIPAA

The HIPAA (Health Insurance Portability and Accountability Act of 1996 ) standard includes the following administrative and financial health care transactions:

• Health claims or equivalent encounter information - 837 dental, 837 professional, 837 institutional
• Enrollment and disenrollment in a health plan - 834
• Eligibility for a health plan - 270, 271
• Health care payment and remittance advice - 835
• Health plan premium payments - 820
• Health claim status - 276, 277
• Referral certification and authorization - 278
• Coordination of benefits - 837

Copies of the X12N implementation guides can be downloaded from the Washington Publishing Company web site at http://www.wpc-edi.com/hipaa/ or by contacting Washington Publishing at 301-590-9337 to purchase a printed copy. Information about obtaining the implementation guide for the NCPDP standard is available from their web site at http://www.ncpdp.org.

During an E-Commerce and HealthCare Conference, Dr. Chiang of Redix International, Inc. made a presentation explaining the practical ways of implementing the Healthcare Claims and Payment Advice. This conference, sponsored by DISA and HIBCC, was held on Oct. 28-30, 1998.  The slides of the talk can be viewed by clicking here.

To help your applications comply with HIPAA standards, Redix International, Inc. has made a HIPAA version of the Redix Format Converter. 

EDI Applications in the Health Care Industry - Introduction

A full range of EDI transaction sets between the payer, employer, and provider was addressed by the insurance subcommittee of X12. Several transaction sets as described below were designed for use within the entire health care and general insurance marketplace.

Health Care Eligibility/Coverage/Benefit Inquiry (270)
Used to inquire about health care eligibility and benefits associated with a subscriber or a dependent under the subscriber's policy.

Health Care Eligibility/Coverage/Benefit Inquiry (271)
Used to respond to Health Care Eligibility/Coverage/benefit Inquiry Transaction Set (270) and provides information about or changes to health care eligibility of benefits.

Patient Information (275)
Used to communicate individual patient information requests and patient information (either solicited or unsolicited) between separate health care entities in a variety of settings to be consistent with confidentiality and use requirements. Patient information consists of demographic, clinical, and other supporting data.

Health Care Claim Status Inquiry (276)
Used by a provider, recipient of health care products or services, or an authorized agent to request information from a health care payer about the status of a health care claim.

Health Care Claims Status Information (277)
Used by a health care payer or authorized agent to notify a provider or authorized agent regarding the status of or to request additional information from the provider about a health care claim.

Health Care Services Review Information (278)
Used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data, for the purpose of requesting for review, certification, notification or reporting the outcome of a health care services review.

Benefit Enrollment and Maintenance (834)
Used to exchange health care consumer insurance enrollment information between a health care sponsor and a payer organization.

Health Care Claim Payment/Advice (835)
Used to make a payment, send an explanation of benefits remittance advice, or make a payment and send an explanation of benefits remittance advice from a health care provider directly or via a financial institution.

Health Care Claim (837)
Used to submit health care claim billing information from health care service providers to payers, either directly or via intermediary billers and claim clearing houses. Used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required.

Healthcare Transaction Flow

For some healthcare transaction sets, there are a number of possible responses.  The list of possible healthcare transaction sets and their possible responses is shown in the following table.