Skillsight has been closely monitoring the Health Insurance Portability and Accountability Act (HIPAA) of 1996. We are assimilating HIPAA regulations into our corporate culture, making them one more element of our customer focus. That means we are constantly looking at HIPAA based on our customers’ needs.
Skillsight is incorporating HIPAA’s Transactions and Code Sets, Privacy, and Security standards into our daily operations. We are also making every attempt to heighten the health care industry’s awareness of the benefits and implications of this legislation. Skillsight is aware we are but one player and that achieving overall success of HIPAA compliance will require an entire health care industry team effort. Therefore, Skillsight is active in the health care industry.
Industry education and support of HIPAA is just one element of our efforts. The list below outlines some of our other HIPAA activities:
- Learning and understanding the complexities of the legislation so we can help our own staff and clients understand it fully.
- Working closely, as discussed, with others in the health care industry toward HIPAA success.
- Committing publicly to support of HIPAA.
- Implementing HIPAA regulations by deadline through a wide range of operational changes and service changes.
- Supporting our clients with education and customer service related to HIPAA.
HIPAA Standard Transactions
HIPAA requires the Secretary of Health and Human Services (HHS) to adopt standards to support electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. After looking at all the various transactions in place such as NSF, HHS selected the ANSI transaction set. ANSI is the American National Standards Institute. They provide standards for exchange of business information under the Accredited Standards Committee, ASC X12. X12 has a subcommittee for the insurance industry called ASC X12N. This committee is responsible for maintaining all insurance transaction formats.
HIPAA mandates the following transaction sets be implemented in a standard format:
- 837 – Claims and encounters
- 835 – Payment and remittance advice
- 270/271 – Eligibility inquiry and response
- 275 – Claim attachments
- 276/277 – Claim status and response
- 834 – Enrollment
- 278 – Referral certification and authorization
The number preceding transaction is the ANSI transaction set. Previously, ANSI version 4010-1A was required to be implemented. Version 4010A1 is now required as of October, 2003. Vesion 5010 is now required to be implemented before 2011/2012.
Electronic claims have been traded between providers and health plans since the mid-1980s. Claim transactions today are submitted in National Standard Format (NSF), ANSI or a health plans proprietary format. NSF has never been a standard because each health plan could create their own implementation guide, requiring different information than another health plan.
HIPAA has done away with this and requires all health plans and providers to use the standard implementation guide. However health plans and providers can use a clearinghouse to translate from proprietary formats to standard formats. For instance, a provider could submit claims to a clearinghouse in NSF as long as the clearinghouse can translate the claim into an 837 transaction before going to the health plan. A health plan can continue to use their proprietary format as long as they have a clearinghouse that can accept ANSI transactions from their providers for them.
Any health plan accepting electronic transactions is required to accept those transactions in this standard format.
Skillsight’s HIPAA 5010 Transition consulting service offering evaluates your existing 4010 translation system and documents recommendations on how your organization can best support the new 5010 transactions in parallel with the existing 4010 processing. Once support for the older standard ceases, the 4010 processing can easily be removed.
Working closely with customer staff, a Skillsight consultant will conduct a comprehensive review of the EDI processing environment and production systems, providing written plans on how to complete the migration with the least impact on existing EDI and other dependent systems.
This diagram shows typical EDI transaction sets by trading partners. Skillsight has the expertise to design, analyze and enhance new and existing EDI Server environments to meet the needs of healthcare trading partners, including providers, payers, sponsors and administrators. The arrows represent the instances where EDI products perform transaction translations between systems and organizations.
Delivery Tasks / Road Map:
Skillsight will provide a smooth transition, with minimum disruption to your current architecture, in migrating to the 5010 standard. With your vital participation, we tailor the engagement to your needs.
Pre-Engagement Customer to provide:
• Inventory of affected EDI translation maps and transaction processes
• Layouts of proprietary data record formats and schemas
• Crosswalk references between the EDI standards and internal data formats
• Requirements for converting each translation map and transaction process
(e.g. business edits and other pre or post processing activities)
Skillsight staff will:
• Review current system wide architecture
• Review current process flow for compliance
• Review current processes for error checking with recovery
• Produce an implementation plan containing work breakdowns and schedules that
will be followed during the engagement
Based on the architectures and designs completed in Phase 1, Skillsight staff will:
• Install or upgrade the Skillsight EDI Server tools
• Develop 5010 based versions of all required EDI translation maps and business processes
• Assist customer EDI developers in producing maps and business processes
• Conduct Unit testing of all newly developed or modified components
• Optionally conduct system level testing to ensure correct processing and error recovery
Documentation and Knowledge Transfer
Upon completion of the EDI system development, Skillsight staff will deliver:
• System level design of the EDI system in relation to other systems with which it interacts
• Completed translation maps, tested to meet customer requirements
• Updated transaction processing platform as needed
• Comprehensive documentation detailing the design of each map, including any extra features such as business edits
• Knowledge transfer sessions with customer staff to review all changes for future development
HIPAA Compliance Testing:
• Type 1: EDI syntax integrity testing
• Type 2: HIPAA syntactical Requirement testing
• Type 3: Balancing
• Type 4: Situation testing
• Type 5: External code set testing