1. Electronic Data Interchange (EDI)
HIPAA Pros - Electronic Data Interchange
Electronic Data Interchange (EDI)
© HIPAA Pros All rights reserved

2. HIPAA National Electronic Transaction Standards
Enrollment and Dis-enrollment in a Health Plan (834)
Health Care Premium Payments (820)
Health Care Eligibility Benefit Inquiry and Response (270/271)
Referral Certification and Authorization (278)
Health Care Claims or Equivalent Encounter Information (837)
Health Care Claim Status (276/277)
Health Care and Remittance Payment Advice (835)
Coordination of Benefits (837)
First Report of Injury (145) (Delayed)
Additional Claim Information (275) (Delayed)

3. Enrollment and Dis-enrollment in a Health Plan (834)
The enrollment and dis-enrollment in a health plan transaction is the transmission of subscriber enrollment information to a health plan to establish or terminate insurance coverage.

4. Health Plan Premium Payments Transaction (820)
The health plan premium payment transaction is the transmission of any of the following from the entity that is arranging for the provision of health care or is providing health care coverage payments for an individual to a health plan.
 Payment

5. Health Plan Premium Payments Transaction (820)
Information about the transfer of funds
Detailed remittance information about individuals for whom premiums are being paid

6. Health Plan Premium Payments Transaction (820)
Payment processing information to transmit health care premium payments including any of the following:
Payroll deductions
Other group premium payments
Associated group premium payment information

7. Eligibility for a Health Plan Transaction (270/271)
The eligibility for a health plan transaction is the transmission of the following:

8. Eligibility for a Health Plan Transaction (270/271)
An inquiry from a health care provider to a health plan, or from one health plan to another health plan, to obtain any of the following information about a benefit plan for an enrollee:
Eligibility to receive health care under the health plan.
Coverage of health care under the health plan.
Benefits associated with the benefit plan.
A response from a health plan to a health care provider’s (or another health plan’s) inquiry.

9. Referral Certification and Authorization Transaction (278)
The referral certification and authorization transaction is any of the following transmissions:
A request for the review of health care to obtain an authorization for the health care.
A request to obtain authorization for referring an individual to another health care provider.

10. Health Care Claims or Equivalent Encounter Information Transaction (837)
The health care claims or equivalent encounter information transaction is the transmission of either of the following:
A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care.

11. Health Care Claims or Equivalent Encounter Information Transaction (837)
If there is not direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care.

12. Health Care Claim Status Transaction (276/277)
A health care claim status transaction is the transmission of either of the following:
An inquiry to determine the status of a health care claim
A response about the status of a health care claim

13. Health Care Payment and Remittance Advice Transaction (835)
The health care payment and remittance advice transaction is the transmission of either of the following for health care:
The transmission of any of the following from a health plan to a health care provider’s financial institution:
Payment
Information about the transfer of funds
Payment processing information

14. Health Care Payment and Remittance Advice Transaction (835)
The transmission of either of the following from a health plan to a health care provider:
Explanation of benefits
Remittance advices

15. Coordination of Benefits Transaction (837)
The coordination of benefits transaction is the transmission from any entity to a health plan for the purpose of determining the relative payment responsibilities of the health plan, of either of the following for health care:
Claims
Payment information

16. First Report of Injury (145)
Delayed

17. Additional Claim Information (275)
Delayed

18. HIPAA Pros - Electronic Data Interchange
PROVIDERS
INSURANCE & PAYORS
SPONSORS
834
270
Eligibility
Verification
Enrollment
811
Enrollment
271
820
Pretreatment
Authorization
and Referrals
Pre-Certification
and
Adjudication
278
837
Service Billing/
Claim Submission
Claim Acceptance
275
276
Claim Status
Inquires
Adjudication
275
277
Accounts
Receivable
835
Accounts Payable
© 2002 Sterling Solutions, Ltd. Used with permission.

19. HIPAA Code Sets
International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM)
Current Procedural Terminology, 4th Edition (CPT-4)
Health Care Financing Administration Common Procedure Coding System (HCPCS)
Code on Dental Procedures and Nomenclature, 2nd Edition (CDT-2)

20. Required Electronic Submission of Medicare Claims
October
Medicare claims must be submitted electronically unless one of the following applies:
There is no method available for submission of claims in electronic format.
The entity submitting the claim is a small provider of services.
Physician practice with fewer than 10 FTEs.

21. Action Required to Apply for Extension
If not in compliance with the Transactions and Code Sets regulation by October 15, 2002:
Must file a compliance plan (extension form).
Extend the deadline to October 16, 2003.
Each covered entity must submit a compliance plan, detailing how they plan to meet the October 2003 deadline.

22. Action Required to Apply for Extension
The compliance plan must contain:
Covered entity identifiers and contact information.
Reason for filing an extension.
Implementation budget.
Implementation strategy.

23. Action Required to Apply for Extension
Model compliance plan provided on the Centers for Medicare and Medicaid Services web site -
Print hard copy and send via Certified mail, or
Submit your own version of a compliance plan that provides equivalent information.

24. Reason for Filing This Extension
Need more money
Need more staff
Need to buy hardware
Need more information about the standards
Waiting for vendor(s) to provide software
Need more time to complete implementation

25. Reason for Filing This Extension (continued)
Waiting for clearinghouse/billing service to update my system
Need more time for testing
Problems implementing code set changes
Problems completing additional data requirements
Need additional clarification on standards
Other

26. Implementation Budget
Less than $10,000
$10,000 - $100,000
$100,000 - $500,000
$500,000 - $1 million
Over $1 million
Don’t know

27. Implementation Strategy – HIPAA Awareness
Projected / Actual Start Date
Projected / Actual Completion Date

28. Implementation Strategy – Operational Assessment
Indicate whether you have completed this phase of the Implementation Strategy. If yes,
Provide projected / actual completion date.

29. Implementation Strategy – Operational Assessment
If Operational Assessment is not complete, provide the following additional information:
Indicate if current processes were reviewed against HIPAA Electronic Health Care Transactions and Code Sets standards requirements.
Indicate if internal implementation issues have been identified and a workplan developed.
Indicate if you plan to or might use a contractor / vendor to help achieve compliance.
Provide projected / actual start date.

30. Implementation Strategy – Development and Testing
Indicate whether you have completed this phase of the Implementation Strategy. If yes,
Provide projected / actual testing completion.

31. Implementation Strategy – Development and Testing
If Development and Testing is not complete, provide the following additional information:
Indicate if software development / installation is complete.
Indicate if staff training is complete.
Provide projected / actual development start date.
Provide projected / actual initial internal software testing start date.

32. What Happens If We Don’t Comply?
Failure to meet the HIPAA deadlines could result in significant fines and prison time.
Failure to submit electronic Medicare claims by October 16, 2003, could lead to exclusion from participation in the Medicare program.
An enforcement regulation has not yet been finalized.