X12N Task Group 3/Work Group 2 July2000 Health Care Transactions ANSI ASC X12N Insurance Sub-Committee Task Group 3 Business Transaction Coordination and Modeling Work Group 2 Health Care Modeling

X12N Task Group 3/Work Group 2 July2000 Purpose of Presentation zGive an overview of the “big picture” of HIPAA transactions ywhat each does yhow they interact with each other

X12N Task Group 3/Work Group 2 July2000 Provider Patient information Subscriber Patient information Subscriber information Prior Authorization/ Referral/CMN Claim/ Encounter Claim Status Payer Sponsor Premium Payment Enrollment 834 Premium Payment 820 Eligibility Response 271 Eligibility Inquiry 270 Request for Review 278 Review Response 278 Claim/Encounter 837 Remittance Advice 835 Status Inquiry 276 Status Response 277 HIPAA Transactions ASC X12N TG3 GW2 Summary of HIPAA Transactions COB Claim Claim/ Encounter Attachments 275/HL7 Request Additional Information 277

X12N Task Group 3/Work Group 2 July2000 “All health care providers who elect to conduct these specific transactions electronically must conduct them according to the standards as well. Health care providers may also contract with a clearinghouse to conduct standard transactions for them.” * * Department of Health and Human Services - Most Frequently asked questions ( HIPAA Impact to Providers

X12N Task Group 3/Work Group 2 July2000 “Health plans may not refuse to accept standard transactions submitted electronically (on their own or through clearinghouses). Further, health plans may not delay payment because the transactions are submitted electronically in compliance with the standards.” * * Department of Health and Human Services - Most Frequently asked questions ( HIPAA Impact to Health Plans

X12N Task Group 3/Work Group 2 July2000 There are two aspects of data content standardization addressed in the HIPAA rules: Data Content ä standardization of data elements, including their formats and definition, and ä standardization of the code sets or values that can appear in selected data elements.  ICD Diagnosis Codes  CPT Procedure Codes  HCPCS Procedure Codes  CDT Procedure Codes  NDC Drug Codes  Others

X12N Task Group 3/Work Group 2 July2000 Modifications to Transactions “Once we publish the final rule in the Federal Register and it is effective, there will be no additional data element or record/segment content modifications in any of the transactions for at least one year.” * * Department of Health and Human Services - Most Frequently asked questions (

X12N Task Group 3/Work Group 2 July2000 Memorandum of Understanding (MOU) äThe MOU addresses future maintenance of the data content within the HIPAA transactions. äIt is the understanding of the combined efforts of  HHS - Health and Human Services  X12N  NUCC - National Uniform Claim Committee  NUBC - National Uniform Billing Committee  ADA - American Dental Association  HL7 - Health Level 7  NCPDP

X12N Task Group 3/Work Group 2 July2000 Sponsor 834 Enrollment Health Plan Provider 270 Eligibility Request Subscriber/Patient Information 271 Eligibility Response

X12N Task Group 3/Work Group 2 July2000 Sponsor 834 Enrollment Health Plan Premium Information 820 Premium Payment

X12N Task Group 3/Work Group 2 July2000 Health Service Review (Authorization) Provider 278 Response to Authorization Health Plan 278 Request for Authorization

X12N Task Group 3/Work Group 2 July2000 Claim / Encounter Submission w/ an Attachment Provider 835 Remittance Advice Health Plan 837 Claim/Encounter Submission 275 Attachment

X12N Task Group 3/Work Group 2 July2000 Claim / Encounter Submission Payer requests additional information Provider Health Plan 837 Claim/Encounter Submission 835 Remittance Advice 277 Request for Additional Information 275/HL7 Attachment

X12N Task Group 3/Work Group 2 July2000 Coordination of Benefits Claim / Encounter Submission Provider-to-Payer Model Provider Primary Health Plan Claim/Encounter Submission Remittance Advice Secondary Health Plan Remittance Advice COB Claim/Encounter Submission

X12N Task Group 3/Work Group 2 July2000 Coordination of Benefits Claim / Encounter Submission Payer-to-Payer Model Provider Primary Health Plan Claim/Encounter Submission Remittance Advice Secondary Health Plan Claim/Encounter Submission with 835 Information Remittance Advice

X12N Task Group 3/Work Group 2 July2000 Claim Status (Solicited) Provider 277 Claim Status Response Health Plan 276 Claim Status Inquiry

X12N Task Group 3/Work Group 2 July2000 For Further Information zThis presentation has been developed by X12N (Insurance) Task Group 3 (Modeling) Work Group 2 (Health Care Insurance). zFor further information contact a Co- Chair of this group, listed on the DISA web site,