HIPAA Transactions and Code Sets
What are the HIPAA standard transactions for electronic submitters?
The standard transaction formats that are mandated by HIPAA are the following:
| Health Care Claim Institutional (837I)|
| Health Care Claim Professional (837P)|
| Health Care Claim Dental (837D)|
| Health Care Claim Payment/Advice (835)|
| Health Care Eligibility Benefit Inquiry and Response (270/271)|
| Health Care Claim Status Request and Response (276/277)|
| Health Care Services Review Request for Review and Response (278)|
| Benefit Enrollment and Maintenance (834)|
| Payroll Deducted and Other Group Premium Payment for Insurance Products (820)|
| NCPDP Telecommunications Standard, Version 5.1 and Batch Standard 1.1|
| Coordination of Benefits|
Will Anthem support the standard transactions?
Anthem supports all of the transaction formats and associated code sets as mandated by HIPAA.
Will Anthem conduct standard electronic transactions with trading partners?
Anthem will conduct standard transactions with trading partners as mandated by the regulations. However, to the extent a transaction is not mandated, we will be happy to work with the trading partner to determine if engaging in the standard transaction is in both parties' best interests.
Will Anthem accept non-standard transactions from employers?
For fully insured accounts: The answer to this question depends on whether the contract is between Anthem and the employer/plan sponsor, or Anthem and the group health plan. If we are contracted with the employer/plan sponsor (who is not a covered entity under HIPAA) to perform transactions, we can accept non-standard enrollment formats, but would encourage the use of the standard format. If we are contracted with the group health plan (who is a covered entity under HIPAA) to perform transactions, we are required to exchange only standard transactions.
For self-funded accounts: The answer to this question depends on whether the contract is between Anthem and the employer/plan sponsor, or Anthem and the group health plan. If we are contracted with the employer/plan sponsor (who is not a covered entity under HIPAA) to perform transactions, we can accept non-standard enrollment formats, but would encourage the use of the standard format. If we are contracted with the group health plan (who is a covered entity under HIPAA) to perform transactions, we are their business associate and would be required to exchange only standard transactions, assuming that the transaction is between Anthem on behalf of the group health plan, and another covered entity, such as a provider. If the transaction is only between Anthem and the group health plan and goes no further, we do not need to use standard transactions. There always needs to be two covered entities in the cycle of the transaction in order to mandate the standard transaction
Anthem’s current intention is not to require non-covered entities to submit HIPAA standard transactions, although we do encourage their use.
What are the HIPAA standard external code sets?
There are numerous coding systems that have been designated as standard or acceptable for use when using the HIPAA mandated transactions. The regulations specify under what circumstance each type of coding is required. Some of these required external code sets include:
| ICD-9-CM Volume 1 and 2: Diagnosis Coding|
| ICD-9-CM Volume 3: Inpatient Hospital Service Coding|
| CPT-4: Physician Services Coding|
| CDT-3: Dental Services Coding|
| DRG: Diagnosis Related Groups|
| NDC (National Drug Codes): Retail Pharmacy|
| HCPCS: Other Health Related Services Coding|
What was the HIPAA extension opportunity?
A one-year extension of the compliance deadline for the Standard Transactions and Code Sets Regulations was enacted into law in December 2001. Covered entities providers, clearinghouses, health plans (other than small health plans) and group health plans that submitted a compliance plan to Centers for Medicare and Medicaid Services (CMS) on or before October 15, 2002, must comply with the Standard Transactions and Codes Sets Regulations by October 16, 2003, rather than October 16, 2002. Small health plans (e.g., receipts of $5 million or less) always had until October 16, 2003, to become compliant. Therefore, they did not have to file for an extension. The extension law did not change the April 14, 2003, compliance date for the Privacy Regulations under HIPAA. (Small health plans have until April 14, 2004 to comply with the Privacy Regulations.)
Did Anthem file for the extension?
Anthem filed for the one-year extension on August 15, 2002. Anthem’s compliance extension form states that we are filing on behalf of Anthem as an entity covered by HIPAA, as well as on behalf of our insured and self-insured group customers (except small health plans), with regard to the services Anthem performs on our customers’ behalf.
Anthem met its compliance obligations with respect to the Standard Transactions and Code Sets Rule prior to the October 16, 2003 compliance date.
Did Anthem file for the extension electronically? Did Anthem receive a Filing Extension Number from Health and Human Services (HHS)?
Anthem’s extension filing was submitted by certified mail, return receipt requested. A signed receipt reflecting that our filing was delivered is on file. Since we did not file electronically, we did not receive the HHS issued Filing Extension Number. We were unable to use the electronic submission approach because language was added to describe that our filing also was submitted on behalf of our customers.
Which ANSI version is required for compliance on or after October 16, 2003, 4010 or 4010A1?
The Addenda adopted in the Final Rule published February 20, 2003, mandating the use of 4010A1, is the industry standard effective October 16, 2003. Therefore, all covered entities submitting or using covered electronic transactions must use the 4010A1 as of October 16, 2003. Use of any other version of the electronic transaction standards by covered entities on or after October 16, 2003 would be non-compliant with HIPAA.
Will Anthem use a clearinghouse for HIPAA compliance?
No, Anthem built internal capabilities to accept all standard transactions. All electronic submitters were notified regarding the process and procedures to begin testing and submitting standard transactions to Anthem.
Will Anthem require certification of all trading partners?
Anthem strongly encourages, but will not require certification of its trading partners. However, if the trading partner should fail a sequence of tests, we will reserve the right to require them to be certified prior to the next test with Anthem.
How will Anthem contract with its trading partners?
As clearinghouses, vendors, and providers commence testing with Anthem, new trading partner agreements will be put into effect.
Will Anthem seek certification of its electronic transactions?
Anthem will be using a third-party testing/validation product to assist with internal and submitter transaction testing and validation.
This FREE on-line tool is available at www.hipaatesting.anthem.com. It offers unlimited testing of your EDI HIPAA transactions. Please contact the EDI Helpdesk for your state identified below to obtain your user ID and password necessary to access this FREE on-line tool. Please note that the FREE on-line tool also is available to software vendors who service Anthem EDI submitters.
Will Anthem use a translator tool for facilitating the electronic transactions?
Anthem uses a variety of translation tools throughout the organization for editing and translating standard transactions.
Will Anthem provide instructions for submitting standard transactions?
Instructions for testing and exchanging transactions are available on Anthem’s web site at www.edi.anthem.com. Select your state, and then click to log onto “Electronic Data Interchange (EDI)” to find the following important HIPAA information:
| EDI Registration Form|
| Testing With Us |
| Testing with Your Software Vendor|
| HIPAA Companion Guide |
| Transaction Specific Companion Documents |
| Trading Partner Agreement|
| Free on-line testing tool|
What is Anthem’s plan to assure the smooth flow of payments during the transitional period?
Anthem is prepared to accept and transmit HIPAA compliant transactions. Anthem also is prepared to continue accepting our current legacy transactions during a transitional period beginning October 16, 2003.
How can I take advantage of the opportunity to continue submitting current legacy system formatted transactions on and after October 16, 2003?
You need to register with our Electronic Data Interchange (EDI) Support Services team and advise that you intend to submit current legacy system formatted transactions for some portion of the transitional period. A complete listing of EDI Support Services is included below.
Are paper claims the only option available should HIPAA testing not be completed by October 16, 2003?
No, the submission of paper claims is not the only option. In fact, you have the option to continue submitting our current legacy system formatted transactions or migrating to a vendor or clearinghouse to submit HIPAA compliant transactions on your behalf. Please contact EDI Support Services for information about vendors and clearinghouses that have successfully completed testing with us. If electronic submissions are not an available option, you are encouraged to use HCFA 1500 red drop out forms.
What other HIPAA assistance does Anthem offer?
| FREE on-line tool available at www.edi.anthem.com for you and your software vendors for unlimited testing of your EDI HIPAA transactions. Please contact the EDI Support Service for your state to obtain your user ID and password necessary to access this FREE on-line tool. |
| Blue Cross Blue Shield Association’s HIPAA Transactions and Code Sets Toolkit. The toolkit is available on Anthem’s web site at www.hipaa.anthem.com.|
| Instructions for testing and exchanging transactions available on www.edi.anthem.com. Select your state, and then click to log onto “Electronic Data Interchange (EDI)” to find the following important HIPAA information: |
| EDI Registration Form|
| Testing With Us|
| Testing with Your Software Vendor|
| HIPAA Companion Guide|
| Transaction Specific Companion Documents|
| Trading Partner Agreement|
What is the purpose of the document that CMS issued this past July 24th?
The Centers for Medicare & Medicaid Services (CMS) recently issued its Guidance on Compliance with HIPAA Transactions and Code Sets after the October 16, 2003, Implementation Deadline. This Guidance includes background information, outlines CMS’ enforcement approach and urges health plans and providers to work together toward compliance. A copy of the document is available on CMS’ web site at http://www.cms.hhs.gov/hipaa/hipaa2/
. The compliance deadline has NOT been extended or delayed; instead, CMS’ communication simply outlines the approach that the government plans to take regarding the enforcement of the HIPAA transactions and code sets provisions.
Whom should I contact to submit HIPAA compliant electronic transactions? Whom should I contact to schedule testing with Anthem?
If you wish to schedule testing with Anthem or to submit HIPAA compliant electronic transactions, please contact the appropriate EDI support service in your state or region:
In Colorado or Nevada:
(303) 831-2973 or (303) 831-2275
Ext. 7172 (institutional)
Ext. 8293 (professional)
Ext. 7172 or 8293 (accounts)
In Indiana, Kentucky or Ohio:
(800) 470-9630 and select option 2
In New Hampshire:
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