Enrollment and Eligibility Implementation Team

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Enrollment and Eligibility Implementation Team
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Charge

• Standards and implementation guides for the
  following transactions
• Enrollment
• Eligibility
• First Report of Injury
• Health Plan Premium Payments
• Referral Certification and Authorization

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Recommendations

• Enrollment - X12.834
• 1st Report of Injury - X12.148
• Premium Billing and Payment - X12.811/820
• Health Care Services Review - X12.278
• Eligibility - X12.270/271

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Enrollment

• Current Implementation Guide Covers Forms of
  Benefits
• Narrower scope for a health care-specific guide
• Policy Are standards imposed by OMB Directive
  15 applicable to HIPAA?
• Are performance measurement and outcome research
  needs covered by HIPAA?

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1st Report of Injury

• No Current Implementation Guide
• Not health care-specific transaction guide
  outside HHS purview
• DoL - OSHA, BLS, OWCP
• Policy Expand to allow physician first report?
• May have to engage private sector workers comp
  community

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Premium Billing Payment

• Used in Industry as ANSI finance function
• No Implementation Guide
• HIPAA Use Not Very Complicated

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Health Care Services Review

• Multiple Implementation Guides Possible
• Limited, If Any, Actual Use
• Pilot Project Underway
• May be a late deliverable for 2/98

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Eligibility

• Mapping Government data element Requirements
• All necessary components in place to produce the
  regulation
• Not doing interactive Eligibility Transactions

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Data Dictionary

• Includes
• Listing of names, definitions, transactions and
  locations
• Organized by individual transactions
• Does NOT include
• Code values
• Implementation instructions

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