TRANSMISSION SET COMPLIANCE
DATES & REQUIREMENTS

Electronic Transaction Standards
Checklist for Compliance

• Inventory current transactions (e.g., claims, preauthorization) and interfaces for compliance with HIPAA transaction standards.
• Determine whether you are going to convert your internal systems or use an outside vendor (clearinghouse).
• Determine what financial resources will be needed to comply with the transaction standards.
• Identify payers, insurers and health plans that your organization deals with and determine how and when they will begin accepting standardized formats and code sets.
• Develop an implementation strategy-work with health plans and other payers: start with the most complex transaction and claims.

Extension
Who Should File

If you are a covered entity and will not be compliant with the HIPAA Electronic Health Care Transactions and Code Sets standards by October 16, 2002, you must file a compliance plan.

• A covered entity is a health plan, a health care clearinghouse, or a health care provider who transmits health information in electronic form in connection with one or more transactions for which the Secretary has adopted standards at 45 C.F.R. Part 162.
• These terms are defined at 45 C.F.R. 160.103. The term "health care provider" includes individual physicians, physician group practices, dentists, other health care practitioners, hospitals, nursing facilities, and so on.

If you are a member of a group practice, the extension will be granted to all physicians/practitioners who are members of that practice. It is not necessary to file separate compliance plans for each physician in the practice if the practice files all claims on your behalf. However, if you submit claims for payment outside of the group's claims processing system, you need to file your own compliance plan.

You do not have to file a compliance plan if you will be compliant by October 16, 2002 but one or more of your trading partners is not yet HIPAA compliant. But remember that you/your organization must be HIPAA compliant by this date (or by October 16, 2003 if you are filing a compliance plan) for all transactions that apply to you.

When to File

Compliance plans must be submitted electronically no later than October 15, 2002. Paper submissions should be postmarked no later than October 15, 2002. Providers who file electronic and paper submissions received electronically or postmarked after this date will not receive an extension.

Transaction Code Sets

Explicitly defined data elements need to be "filled" with standardized data from HIPAA prescribed code sets. Industry de facto standards have been adopted for the coding of medical data elements, such as, diagnoses, procedures, and drugs. These code sets have been developed by public and private organizations and are currently mandated for use in Medicare and Medicaid documentation. Because of the widespread use of these "standards", they have been adopted by ASC X12N and the National Council for Prescription Drug Programs (NCPDP) and recommended for inclusion in the HIPAA standards. Familiarity with these standards is comforting in a time of sweeping changes in the healthcare industry. Most of the players in the healthcare industry will easily recognize the following required code sets:

• ICD-9-CM (vol. 1 & 2)
  Diseases, injuries, impairments, other health related problems, their manifestations, and causes of injury, disease, impairment, or other health-related problems
  
  
• CPT, CDT, or ICD-9-CM (vol. 3)
  Procedures or other actions taken to prevent, diagnose, treat, or manage diseases, injuries and impairments
  
  
• NDC
  Drugs
  
  
• HCPCS
  Other health related services, other substances, equipment, supplies, or other items used in health care services

Characterized as "smaller code sets" by the HIPAA Transaction Standard are sets of codes for data elements such as type of facility, type of units, and specified state within address fields. Familiar to us in this category are the U.S. Postal Service 2-character state abbreviations and zip codes. Other proprietary code sets will be eliminated if not explicitly mentioned in the Implementation Guides. The standards clarify that newly developed code sets may appear in response to the needs of future transaction standards.

Centers for Medicare & Medicaid Services FAQ

(February 21, 2002) - The Centers for Medicare and Medicaid Services has issued a document answering two dozen frequently asked questions about the Administrative Simplification Compliance Act. Signed in December, the act extends by one year the Oct. 16, 2002, deadline for complying with the final HIPAA transactions and code sets rule for covered entities that apply for an extension. For a copy of the document, send an e-mail to joseph.goedert@tfn.com. Among the clarifications in the document:

• The law does not require federal approval or disapproval of applications, called extension plans. “Submission of an extension plan is sufficient to secure the one-year extension,” according to the document. However, the Department of Health and Human Services will submit a sample of extension plans to the National Committee on Vital and Health Statistics. The committee will review the sample to identify problems complicating compliance activities and will recommend corrective actions.
  
  
• In general, information in extension plans is subject to public disclosure under the Freedom of Information Act.
  
  
• HHS will publish a model extension plan form by March 31 and strongly recommends its use, although it won’t be mandated. The department will issue instructions for submitting the plans and requests they not be sent until the instructions are released.
  
  
• A covered entity fully compliant by the original October 2002 deadline need not submit an extension plan because trading partners are not ready.
  
  
• HHS will publish a proposed rule governing exclusion from the Medicare program of covered entities that are not compliant by October 2002 and do not submit an extension plan.
• HHS will publish a proposed rule prohibiting payment of Medicare claims that are not submitted
  
  electronically after Oct. 16, 2003, with limited exceptions.