HIPAA Transactions Testing Update. Kepa Zubeldia, M.D. September 13, 2004
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1 HIPAA Transactions Testing Update Kepa Zubeldia, M.D. September 13, 2004
2 HIPAA Transactions Convergence Kepa Zubeldia, M.D. September 13, 2004
3 Topics Before HIPAA The HIPAA goal Reality today Companion Guide Portal Progress Report Convergence Project Open invitation 2
4 The HIPAA Law (1996) SEC (a) CONDUCT OF TRANSACTIONS BY PLANS. (1) IN GENERAL. If a person desires to conduct a transaction referred to in section 1173(a)(1) with a health plan as a standard transaction (A) the health plan may not refuse to conduct such transaction as a standard transaction; (B) the insurance plan may not delay such transaction, or otherwise adversely affect, or attempt to adversely affect, the person or the transaction on the ground that the transaction is a standard transaction; and (C) the information transmitted and received in connection with the transaction shall be in the form of standard data elements of health information. 3
5 Transactions NPRM, May The health care industry recognizes the benefits of EDI and many entities in that industry have developed proprietary EDI formats. Currently, there are about 400 formats for electronic health care claims being used in the United States. The lack of standardization makes it difficult to develop software, and the efficiencies and savings for health care providers and health plans that could be realized if formats were standardized are diminished. 4
6 Final Rule, Transactions, August 17, 2000 In addition, we disagree with commenters that we should add a new usage statement, not required unless specified by a contractual agreement, in the implementation guide. We believe that the usage statement would have the same effect as allowing trading partners to negotiate which conditional data elements will be used in a standard transaction. Each health plan could then include different data requirements in their contracts with their health care providers. Health care providers would then be required to use a variety of guidelines to submit transactions to different health plans. This would defeat the purpose of standardization. (Page 50323) 5
7 Trading partner agreements. A covered entity must not enter into a trading partner agreement that would do any of the following: (a) Change the definition, data condition, or use of a data element or segment in a standard. (b) Add any data elements or segments to the maximum defined data set. (c) Use any code or data elements that are either marked not used in the standard s implementation specification or are not in the standard s implementation specification(s). (d) Change the meaning or intent of the standard s implementation specification(s). 6
8 High expectations from HIPAA The HIPAA standard transactions will be acceptable to all covered entities (payers and clearinghouses) If a provider or clearinghouse sends a claim that meets the HIPAA Standard (IG) then the payer is required to accept it without imposing additional requirements. 7
9 The Reality Today There are many additional requirements imposed by the payers Contractual Other laws and regulations Telecommunications Implementation restrictions Data formatting requirements Data content requirements Most additional requirements are reasonable 8
10 Examples of Requirements Used / not used segments and elements Functionality not yet implemented Data formatting requirements No punctuation in names and addresses Maximum of xx bytes in patient account number Dollar amounts must have trailing.00 Data content requirements Provider identifiers (may go away with NPI) Anesthesia units or minutes Specific provider name spelling Unique code set restrictions, procedure modifiers, etc. 9
11 Where are these requirements? Payer HIPAA Companion Guides Provider Bulletins and Newsletters Instructions for filing different types of claims DME, Anesthesia, Home Health, Ambulance, etc. Joe s head Does anybody know why we require this? 10
12 How many sets of requirements? Before HIPAA Transactions NPRM reports 400 formats in use Proprietary formats under the control of each payer or clearinghouse After HIPAA Three standard X12 formats for claim + NCPDP National standard, not under the control of any one payer or clearinghouse Claredi has identified 980 Companion Guides as of September 1, 2004 for the X12 HIPAA transactions. Number keeps growing. 11
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19 Claredi s Companion Guide Portal Free resource on the Internet Lists all the companion guides we have identified, with version number and date Links to the guides themselves Only for guides available through the Internet (65%) Some guides are restricted distribution Next task: locate the NCPDP Payer Sheets 18
20 Statistics as of September 1, P I D Request Response
21 Final Rule, Transactions, August 17, 2000 In addition, we disagree with commenters that we should add a new usage statement, not required unless specified by a contractual agreement, in the implementation guide. We believe that the usage statement would have the same effect as allowing trading partners to negotiate which conditional data elements will be used in a standard transaction. Each health plan could then include different data requirements in their contracts with their health care providers. Health care providers would then be required to use a variety of guidelines to submit transactions to different health plans. This would defeat the purpose of standardization. (Page 50323) 20
22 But Companion guides don t tell the whole story Many edits are not documented in the guides Some guides requirements are not enforced Reading the guides is very difficult Most providers offices can t read more than 2-5 Most vendors won t implement more than 2-5 Medicare, Medicaid(s), Blues There has to be an easier way How do we help in converging these requirements into common requirements? 21
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24 Claredi s Convergence Project To help the healthcare industry converge on a manageable set of requirements for the HIPAA transactions To help identify the divergent requirements To automate the identification of requirements in a machine processable format To provide a convergence model usable for other transactions like those in the NHII Free, open to the entire industry 23
25 Convergence Interoperability Data Content standards driven by NUBC, NUCC, ADA DeCC, NCPDP, WEDI, others Industry should adopt these standards as reference point, or target for convergence Feedback mechanism: compare transaction requirements among participants Deviation from requirements defined by Content Committees, industry associations and others Deviation from other requirement from same payer Deviation from requirements from other payers 24
26 HIPAA Convergence Requirements Lists General Convergence Lists Define common requirements as target for convergence Bill type Type of claim Lists defined by NUBC, NUCC, DeCC and NCPDP for the entire industry Payer Specific Lists Defined by each payer for their own needs Concise, limited only to payer-specific needs Does not replace companion guides. Supplements them. Eventually these lists should go away (Probability 0%) 25
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45 Convergence Project Requirements Lists Will be published by NUBC, NUCC, ADA DeCC and NCPDP Payers should publish their own specific lists Claredi provides the infrastructure Free industry access to requirement list database Each list publisher maintains its own lists Claredi will define initial set of payer-specific lists as part of our Companion Guide implementations, to seed the directory 44
46 The goal: Convergence A single web portal where the companion guides can be referenced and the requirements can be published Easy to read and understand requirements lists Downloadable in machine readable format (XML, CSV) Easy to compare requirements among lists Does not replace Companion Guides Ultimate goal is convergence of requirements Only lists that should remain are the NCPDP, ADA DeCC, NUBC and NUCC-defined lists (Probability 0%) Free access to the industry Open invitation to participate to all interested parties 45
47 Questions? Convergence Project URL 46
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