The Most Common HIPAA Compliant Transactions

In today’s medical practice HIPAA regulations provide both guidance and compliance standards for all financial and administrative procedures involved when it comes to protected health information (PHI). With patient privacy on the line these standards cover all key transactions in which organizations collect, handle, and store their information. Complying with these standards will protect the medical practice against theft and violations along with helping to ensure their patient information is secure.

The Centers for Medicare and Medicaid Services (CMS) defines a transaction as, “an electronic exchange of information between two parties to carry out financial or administrative activities related to healthcare.” Because of its many benefits, processing patient information electronically in today’s medical practice is commonplace. Such benefits include increased operations and efficiencies, more accurate information, and the overall reduction in cost to the medical practice.

However, because of the rise in electronic transactions patient information may be at risk. As a result, HIPAA has enacted guidelines to provide oversight to organizations that handle PHI. Those transactions regulated by HIPAA include:

• Healthcare plan enrollment
• Healthcare plan premium payments
• Verification of patient eligibility to receive care at a medical practice
• Authorization of a patient’s referral to receive specialized services or care from another doctor
• Claims filing and other benefits related processes
• Claims attachment
• Verification of claims status
• Explanations of benefits or remittance advice

Standardized HIPAA Transaction Code Sets

To further streamline the process, eliminate barriers, and keep everyone on the same page, the Administrative Simplification Provisions of HIPAA were enacted. They are also used as a means to communicate electronic data using a single set of standards. These standardized transaction code sets are listed below and fall into three categories:

Standardized Transaction Code Sets and Identifiers

1. Current Procedural Terminology (CPT®)
2. ICD-10-CM
3. Provider ID
4. Carrier ID
5. Health Plan ID
6. Provider Taxonomy Codes

Standard HIPAA Transaction Formats

1. ANSI-American National Standards Institute
2. ASC-Accredited Standards Committee
3. X12-Specific Committee within ASC
4. N12-Insurance Subcommittee within X12
5. 5010-ASC X12 Standard; which replaces the ASC X12 version 4010A1

Standard Transaction Code Formats for Physicians

1. 837P-This is the standardized form used by physicians, suppliers and other non-institutional providers to transmit health care claims electronically.
2. 837I-This standardized form used by institutional providers such as hospitals, nursing facilities, inpatient and other health care providers transmits health care claims electronically.
3. 837D-This is the standardized form used by dental care providers to transmit health care claims electronically.
4. EDI 835-Also known as the Electronic Remittance Advice (ERA) it is the electronic transaction that provides claim payment information. For medical practices it can be very beneficial since it can be used to auto-post claim payments into their systems.
5. 270 and 271-Used in conjunction with each other the 271 is the Health Care Eligibility/Benefit Response and is used to transmit the information requested in a 270 or Health Care Eligibility Inquiry.
6. 278-Request for Review and Response for Pre-certification and Referral Authorization
7. 276-Claim Status Request
8. 277-Claim Status Response

As a busy medical office manager, time may not always be on your side. With fires to put out and paperwork piling up, it can be difficult to keep ahead of HIPAA regulations. Understanding and applying these regulations is essential to keeping your organization in compliance. Our new HIPAA Compliance ebook provides best practices to help protect your medical office. Download it today.