HIPAA Transaction Compliance
Can it be simplified?

HIPAA transaction compliance (HIP'uh - tran-SAK'shin - kuhm-PLI'ins) Acronym (Health Insurance Portability and Accountability Act).

1. Hospitals that send electronic claims directly to payers must use the "standard" adopted by the Secretary of Heath and Human Service - namely the ASC X12N 837 Version 4010A1.

2. Please note that although this article intends to discuss the HIPAA claims transaction standard, HIPAA involves many transactions.

Let's outline an efficient approach to meeting the "standard" for HIPAA transaction compliance: one that still requires hard work, clear communication, great timing and smooth coordination between providers, payers and all of us at Gaffey + Associates. Consider our approach - minimize your risk of non-compliance and maintain a steady cash flow - while using the required HIPAA standards and meeting the transaction deadline requirements.

We learned a tremendous amount from our experiences with certification testing, companion guide reviews and actually sending LIVE production claims directly to Medicare. One thing became very clear: the complex process of HIPAA compliance can be broken down into risk avoidance phases.

Gaffey + Associates has discovered many variations about how providers are preparing to provide the data needed to send standard HIPAA compliant claims. Because the HIPAA standard transaction is bigger and contains more data than the UB92, most questions and efforts surround the issue of providing missing data. For instance, many providers have asked us, "What data is needed for the standard, what data is needed to get my claims paid, and where do we get this extra information?"

Let's highlight some of the questions from the Gaffey + Associates mailbox:

Q: What data is needed for the standard?

A: Essentially, the necessary data to meet the standard includes:

• All required information in the Implementation Guide must be sent to meet the HIPAA ASC X12 standards, and only enough situational data (data that depends on the each payer's requirements) needs to be sent to adjudicate your claims properly.
• By reviewing each payer's companion guides in context with the HIPAA standard guides, we can verify what data is required.
• If more data is sent, the payer has to accept it but it doesn't have to be used by the payer. Similarly, the situational data doesn't have to be sent unless the payer specifically requests this data. Additionally, many of the required data elements on the HIPAA standard transaction can be placed into a profile or defaulted and sent each time a file is sent to the payer.

Q: What data is needed to get my claims paid?

A: As stated in our last answer, the data that is required to meet the HIPAA standard must be sent. Additionally, those identification data elements and situational items required by each payer's companion guides must be sent.

Q: Where do we get this extra information?

A: Gaffey + Associates has a three-pronged strategy to build HIPAA compliant claims that has proven itself as the best approach for hospitals:

• Gaffey + Associates has determined that, for most payers, the data required to meet the standard and get your claims adjudicated is either on the UB92 print image,
• Or can be loaded into a table when sending to each payer,
• Or can be gap-filled because the payer is not currently editing the data.

Q: Am I spending my time wisely working on providing the 837-4010 transaction instead of the UB92 print image?

A: Yes, supplying a valid 837-4010 standard transaction to your GEMS system ensures all possible data is provided to GEMS in the standard transaction, whether or not it's needed by the payer.

In sending your HIPAA compliant claims to your payers, it is our job as your EDI vendor to confirm and verify their compliance. All providers should eventually be working with their EDI vendor towards a complete 837 Version 4010A* data set. Some providers are working to provide this standard data file as a transaction to Gaffey + Associates right now, while others have chosen to table it until after October.

So…does HIPAA transaction compliance need to be so complicated? Absolutely not! Ask us your questions, educate your staff and minimize your risk of non-compliance, maintain a steady cash flow, use the required HIPAA standards and meet the transaction deadline requirements!

*§162.923(a) General Rule. Except as otherwise provided in this part, if a cover entity conducts with another covered entity (or within the same covered entity), using electronic media, a transaction for which the Secretary has adopted a standard under this part, the covered entity must conduct the transaction as standard transaction.

HIPAA Standard Transactions
Which standards will Gaffey + Associates support?

As you know, the HIPAA standard transactions will be the required national standard for electronic claims October 16, 2003.

However, New Jersey's HINT legislation requires the HIPAA standard transactions become effective October 1, 2003! By that day:

• All institutional claims sent from your hospital to your payers, using GEMS, must be in the HIPAA standard format.
• Likewise, eligibility inquiries and claims status requests must be made using the national HIPAA standard. The payers must send responses to your eligibility inquiries and claims status requests in the national standard format as well.

While our main focus at Gaffey + Associates is to preserve and enhance cash flow by focusing on the electronic claims and the remittances vouchers, we intend to support the claims status and the eligibility request standards as well. Here's a brief summary about each HIPAA standard transaction Gaffey + Associates will support:

• Transaction 837-4010A1 - Claims: This is the normal transaction providers use to send claims to payers and/or clearinghouses. If sending to payers directly, you will use this 837-4010A1 standard. Clearinghouses (WebMD) can legally accept any format and translate it. Gaffey + Associates will send them the 837-4010A1 standard format.
• Transaction 835-4010A1- Remittance Vouchers: Gaffey + Associates will continue to gather the 835-4010 remittances and create human readable reports and data files for your accounting systems.
• Transaction 276/277-4010A1 - Claims Status: The 276-4010A1 transaction requests claim status at claim or line level. Exact claim information should be supplied by the hospital or several pieces of data about the claim(s) can be supplied.
  • The 277-4010A1 response is used by the payer to transmit current claim status back to the hospital. If the hospital request does not give exact claims information, the payer may send the status on a range of claims. Each payer will vary according to detail provided. We have learned that many payers will provide their current status reports along with the new HIPAA standard.
    
• Transaction 270/271-4010A1 - Claims Eligibility: The 270-4010A1 request asks "Is this patient eligible for coverage today?" The potential information set can be large but HIPAA only requires the payer respond to this minimum:
  • The 271-4010A1 responses from the payer must at least answer "Yes, this patient is an eligible member today, not eligible or we can't find this patient on our system". The transaction can provide a much larger set of information but that depends on each payer.
• Transaction 277-4040 Unsolicited Claim Acknowledgement: This claim acknowledgment transaction gives the hospital a report about which claims were accepted into adjudication and which claims were not accepted into adjudication. No status request needs to be made by the hospital. This transaction is automatically sent, like proprietary status reports that are sent today for some payers. Although, this is a required transaction under New Jersey's HINT, and is not a HIPAA required transaction, Gaffey + Associates will support this very important transaction.

The HIPAA standard code sets, namely ICD9-CM diagnosis codes, AMA's CPT® procedure codes and CMS's Level II HCPCS code sets are included in the HIPAA standards transactions. Gaffey + Associates currently supports all of these code sets - with validity edits and various payer specific edits available in GEMS.

Only HIPAA supported code sets are used to build HIPAA standard claims transactions. Gaffey + Associates is successful in sending production HIPAA compliant claims: GEMS is currently trading HIPAA compliant production with Medicare (Riverbend) using the 837-4010 transaction in New Jersey and we will have several other hospitals LIVE in New Jersey in the next several weeks!

HIPAA Testing
New features in GEMS!

GEMS now includes a HIPAA 837 Downloader, which is rolling into hospital business offices across New Jersey. Has it reached your office yet? 1

The new 837 Downloader enables your office to:

• Create standard 837-4010A1 test files from your hospital's data and send them to Medicare and WebMD directly.
• Send 837-4010A1 test files to Claredi for third party testing of your claims!

While more payers become certified, the GEMS 837 Downloader screen will have you sending 837-4010A1 claims in Live production status! From today to October 1, 2003 the 837 Downloader will enable your business office to send Live production claims to payers who have certified Gaffey + Associates as HIPAA compliant OR your hospital as HIPAA compliant.

To find the 837 Downloader screen in GEMS:

• Click the "Download Claims" tab.
• Select the "837 Downloader" tab.
• Select the "Run 837-4010 Downloader" button.

The screen looks like this:

Figure 1 - GEMS 837 Downloader -Downloads Test or Production 837-4010A1 (HIPAA version) files.

Note the left-hand column of the screen: This is a list of all the payers currently becoming certified. As they are made available, these payers will allow your business office to download the 837-4010A1 format!

"What payers are available right now?" Gaffey + Associates is certified HIPAA compliant with New Jersey Medicare (Riverbend GBA). Currently, the CI31 Medicare Inpatient, NJ and the CO31 Medicare Outpatient, NJ transactions are built, enabled and tested.

Commercial claims, followed by the Blue Cross Blue Shield payers, will become available shortly.

Gaffey + Associates resources are available to teach how to use the 837 Downloader screen. If any questions arise regarding how the GEMS 837 downloader works, testing or other HIPAA compliance questions, contact Gaffey + Associates right now.

GEMS IT Update

Gaffey + Associates recently began a relationship with WebEx Communications, Inc. (www.webex.com).

Please note there is now a WebEx Access Anywhere icon in the Taskbar on your server. If you cannot locate the new icon contact our Helpdesk immediately.

In an effort to maintain superior customer support, our IT staff offers Access Anywhere to ensure efficiency in GEMS updates and real-time monitoring of your claim submissions.

User names and passwords are required and promote security of private health information.

For further information on WebEx services and the added value they bring your business office, contact our IT department or Helpdesk representatives directly.