Frequently Asked Questions About Electronic Data Interchange (EDI)
What should be done with software other than HSIS to become EDI compliant?
What are the standard transactions?
Where can I find a listing of HIPAA standardized Explanation of Benefits (EOB) codes?
Is it necessary to file an extension if EDS is not HIPAA ready and we are?
When completing the DMA HIPAA survey, should I use the provider number for my own agency?
Who is responsible for submitting the compliance plan?
Would the county manager be the authorized person to submit the compliance plan for the county?
Why would we need to file a compliance plan?
Where can I get a copy of the implementation guides for EDI/TCI for implementation?
Q.
Will the Office of Local Health Services, Division of Public Health, be
submitting a plan to federal DHHS on behalf of local health department
to take advantage of the extension under the EDI Rule?
A. No.
Q.
Should each local health department submit their own plan to take advantage
of the extension granted by Congress for the EDI Rule?
A.Legal guidance was sought from the Attorney General's Office by the
N.C. DHHS Project Management Office (PMO) and from the Institute of Government
by the N.C. Association of Local Health Directors. A two-page document
entitled "Legal Guidance For Filing HIPAA Compliance Plans"
was originally distributed to all local health directors and HIPAA coordinators
on May 10, 2002, and was re-distributed on June 19, 2002.
Q.
What should be done with software other than HSIS to become EDI compliant?
A. The following steps are suggestions to assist in becoming EDI compliant
and to ensure that your claims will be paid in a timely manner.
- Inventory all software and system applications that are being used to transmit standard transitions electronically (includes insurance companies, Medicare, and Medicaid other than HSIS transmitted claims).
- Contact all software vendors to determine their HIPAA compliance plans and status. If the vendor is not planning to remediate their software to become HIPAA compliant, another software will be needed to electronically transmit standard transactions.
- If the software vendor is planning to become HIPAA compliant, ask for information about targeted compliance dates and whether or not they are taking advantage of the extension to the EDI Rule.
- Inform the software vendor of your HIPAA compliance status and targeted compliance dates.
- Ask if the vendor is planning to send software updates or if they are planning to send totally new software. Be sure to inquire about targeted dates for the updates or new releases and whether or not there are costs involved. Many maintenance agreements include clauses that state that federally mandated changes will be made at no cost to the purchaser. Review your maintenance agreement to determine whether or not you have this advantage.
- Ask for information about planned testing dates and your responsibility during this process. Seek information (names and phone numbers) of appropriate staff within their agency to contact during the testing phase.
- Ask for information about their certification and verification process.
- Ask the vendor to send written documentation to you regarding the above mentioned information to document due diligence for your HIPAA compliance efforts.
Q.
What are the standard transactions?
A. Part 160.103 defines a transaction as "the exchange of information
between two parties to carry out financial or administrative activities
related to health care." The standard transaction are as follows:
- X12N 837 - Professional Healthcare claim or encounter
- X12N 837 - Institutional
Healthcare claim or encounter
- X12N 837 - Dental Healthcare claim or encounter
- X12N 835 - Health Care Claim Payment/Remittance Advice
- X12N 270 - Health Insurance Eligibility request verification for covered benefits
- X12N 271 - Health Insurance Eligibility response verification for covered benefits
- X12N 834 - Enrollment/Disenrollment to a health plan
- X12N 276 - Health Care Claim, inquiry to request the status of a health claim
- X12N 277 - Health Care Claim, response to request the status of a health claim
- X12N 278 - Health Care Services, to request authorizations and referrals
- X12N 820 - Premium Payment, for enrolled health plan members
The Administrative Requirements of each of these transactions can be found in Part 162.
Q.
Where can I find a listing of HIPAA standardized Explanation of Benefits
(EOB) codes?
A. Go to the following website:
http://hipaa.wpc-edi.com/HIPAA_40.asp
In the center column of the page, click on "Code Lists" in the
center menu and you will be able to find a listing of all the standard
transaction codes. You will need to create a user id and password in order
to download and print the listings. If you print them yourself there is
no charge and the web site gives information on the number of pages required
to print. If you choose to order large documents, prices and ordering
information are included on the web site.
Q.
Is it necessary to file an extension if EDS is not HIPAA ready and we
are?
A. If EDS does not plan to become HIPAA compliant with the EDI regs by
October 16, 2002, it is their responsibility to file for the extension.
If your agency is EDI ready by 10/16/02, you are not required to file
for the extension.
Q.
Our county uses HSIS to print HCFAs on paper to submit to insurance companies.
May we continue to submit paper claims or will we be required to file
electronically after October 2002?
A. There are no plans at this time to discontinue allowing health departments
to print HCFA paper claims from HSIS. HIPAA does not require electronic
submission of claims to insurance companies. However, the Administrative
Simplification Compliance Act (ASCA), more commonly known as the EDI extension,
that was final in December 2001, does include a provision that all Medicare
claims must be file electronically by October 16, 2003. At this time,
it is not known whether or not HSIS will be made capable of filing electronic
Medicare claims.
Q.
In the April NC Medicaid Bulletin, page 11, there is a questionnaire regarding
billing and software that DMA is requesting providers complete. Should
health departments complete and submit this survey?
A. Yes, however, it is not mandatory. When completing the survey, use
the Medicaid provider number assigned to your agency.
Q.
When completing the DMA HIPAA survey, should I use the provider number
for my own agency?
A. Yes.
Q.
How can I get a copy of the Administrative Simplification compliance plan
in order to take advantage of the one year extension?
A. Instructions for obtaining the compliance plan:
- Access the website: http://www.cms.hhs.gov/hipaa
- Scroll down to the paragraph entitled "HIPAA Administrative Simplification"
- Click on "Standard Model Compliance Form" at the end of the paragraph.
- At the bottom of the page, there is a shaded bar marked "Begin Electronic Submission Process." This will link you to the instructions and then to the electronic form itself. Don't start the electronic process until you are ready to completely fill out and submit the form. Use the paper version to review the form and have your answers ready prior to beginning the electronic process.
- The paper version of the form is underneath the shaded bar in the last paragraph on the page. Click on the link in the paragraph to view and print a paper version of the form.
Providers are strongly urged to use the electronic mechanism to file compliance plans because it will provide an automatic electronic confirmation number. If plans are filed on paper, no confirmation number will be provided.
Q.
I cannot open the paper version of the Compliance Plan on the CMS website.
How can this document be opened?
A. You must have Adobe Acrobat Reader, Version 4.0 or higher, on your
computer. Using a lower version will not allow the PDF file to open. Contact
your IT staff for assistance.
Q.
Who is responsible for submitting the compliance plan?
A. Please refer to "The Legal Guidance for Filing HIPAA Compliance
Plans" from the Institute of Government. The guidance was initially
distributed to health department staff in an email dated May 10, 2002.
It was redistributed on June 19, 2002.
Q.
We would like to file an extension plan to cover the health department,
DSS, and EMS. Is it possible to list multiple covered entities on one
electronic form or would each entity have to submit their own form?
A. If the county has been declared a hybrid entity, it is permissible
to submit one plan for the entire county. It is also permissible to submit
separate compliance plans for each agency if each agency is operating
under separate implementation plans.
The electronic mechanism for filing compliance plans on the CMS website also has the capability for allowing users to submit multiple compliance plans for a covered entity.
Q.
Would the county manager be the authorized person to submit the compliance
plan for the county?
A. The compliance plan can be filed by the county manager or the county
manager can designate anyone to be the authorized person to file the plan.
Q.
Why would we need to file a compliance plan?
A. Congress passed the Administrative Simplification Compliance Act (ASCA),
Public Law 107-105, on December 27, 2001. The ASCA requires covered entities
to submit a compliance plan by October 15, 2002, if they cannot be in
compliance with the EDI Rule by the October 16, 2002, deadline. Covered
entities do not have to file a compliance plan if they will be compliant
with the EDI rule by October 16, 2002.
Q.
Where can I get a copy of the implementation guides for EDI/TCI for implementation?
A. You may find implementation guides for EDI/TCI at the following website:
http://hipaa.wpc-edi.com/HIPAA_40.asp
Q.
Is it permissible for covered entities to submit electronic claims to
Medicaid and paper claims to insurance companies?
A. Yes.
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