What Every Provider Should Know about HIPAA Transactions

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What Every Provider Should Know about HIPAA
Transactions

• Presented by Susan J. Fox
• Fox Systems, Inc.
• www.foxsys.com
• www.hipaaconsulting.com
• susan.fox_at_foxsys.com

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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?

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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

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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 Cant Figure It Out!

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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!

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Why Are StandardsImportant 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

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MN1412MARY SMITH CLEARINGHOUSE460003000 P
ERICMARY SMITHTE9135551234FX6123334567ED61
25559876 NM!402MEDICARE PART B46 WHY
INC HL1201 MNI852EYEBALL SURGERY
ASSOCIATES24123456789 N3PO BOX
1234 NSALISBURYMO660453565US REF1C09876 P
ER1CBILLING PROVIDER CONTACT OFFICE
NURSETE9135551234FX 6123334567TE
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What Your Computer Sees During an 837
Transaction
8
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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

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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)

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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

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HIPAA Non-medical Codes

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

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

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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

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Business Associates Trading Partners

• 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

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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

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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

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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)

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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

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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

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Check List - Billing/PM Vendors

• Confirm that your system has controls to prevent
  the entry of non-compliant values
• Has your systems 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

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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

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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

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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

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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/info
serie/. Series also available in Spanish.