HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires that claims submitted electronically, effective October 16, 2003, be in a format that complies with the appropriate standard adopted for national use. Today, ANSI ASC X12N 837 Professional Format Version 4010.A1 is the standard for submitting EDI claims.

The Administrative Simplification and Compliance Act (ASCA) requires that claims be submitted to Medicare electroncially by October 16, 2003, with some exceptions. However, a HIPAA Contingency Plan has been invoked to temporarily accept electronic claims in a non-HIPAA compliant format/version after October 15, 2003, while submitters complete implementation and testing efforts. To encourage HIPAA compliance, the Centers for Medicare and Medicaid Services (CMS) has modified its HIPAA Contingency Plan. The modification continues to allow submission of non-compliant EDI claims; however, the payment of non-HIPAA compliant electronic claims will be delayed.

Beginning July 1, 2004, EDI claims received in a non-HIPAA compliant format/version will be considered as eligible for payment on the 27th day after the date of receipt--not the 14th day. HIPAA-compliant EDI claims will continue to be considered as eligible for Medicare payment on the 14th day after the date of receipt. For example, HIPAA compliant claims received on July 1, 2004, can be paid as early as July 15, while a non-HIPAA compliant EDI claim received on July 1, 2004, can be paid no earlier than July 28. Read the CMS Medlearn Matters article for more information.

While the HIPAA Contingency Plan remains in place (for now), it will take longer to receive Medicare payments for EDI claims submitted in a non-HIPAA compliant format/version. And when CMS concludes the HIPAA Contingency Plan, you will experience a negative cash flow problem if you are not HIPAA compliant. Electronic claims received after the HIPAA Contingency Plan has ended will be rejected if they are not submitted in ANSI ASC X12N 837 version 4010.A1, the HIPAA compliant format and version. The rejection message that will appear on your Submission Summary Report is "Version 4010A1 Required."

If you aren't already submitting your Medicare Part B medical claims in the X12N 837 version 4010.A1, you must take the following steps to comply with HIPAA before the HIPAA Contingency Plan ends:

Contact your vendor immediately to upgrade your software program and/or billing system. If you are switching software vendors, billing services, and clearinghouses, you will also need to reenroll with Highmark Medicare Services Medicare EDI Services to update your EDI profile and/or obtain a new Submitter ID, depending on the circumstances. Your EDI enrollment request will be processed on a first-come, first-served basis. We cannot guarantee your EDI enrollment request will be processed before the HIPAA Contingency Plan ends. So it's important to take action immediately and not wait until the last minute, or your cash flow will be negatively impacted.

Schedule software training with your vendor for your staff.

Depending on your software vendor, you may need to submit a test file using X12N 837 4010.A1 before you are approved to use it in a production mode. Your test(s) will be reviewed on a first-come, first-served basis. We cannot guarantee your test will be reviewed before the HIPAA Contingency Plan ends. So it's important to take action immediately and not wait until the last minute, or your cash flow will be negatively impacted.

Once you are approved for production using X12N 837 version 4010.A1, you will need to notify Medicare when you are ready to migrate to X12N 837 version 4010.A1.

Remember! If you are using 837 version 4010, you still need to upgrade to X12N 837 version 4010.A1 before the HIPAA Contingency plan ends. No additional testing is required to migrate from version 4010 to 4010.A1. Simply send your claims using X12N 837 version 4010.A1 and we will automatically update your profile to reflect your HIPAA compliance. (This is for X12N 837 version 4010 approved customers only.)

For more information, click on the links below to various websites containing valuable HIPAA information. To register for HIPAA testing at Highmark Medicare Services, click on the "Hungry for HIPAA" hippo or contact Medicare EDI Services at 1-866-488-0546, select option 1.

Want to Learn about HIPAA?

Click here to learn about HIPAA and how the Administrative Simplification provisions of HIPAA will help remedy today's ineffecient way of electronic billing to multiple insurers.

Click here to view a slideshow developed by the Centers for Medicare and Medicaid (CMS) regarding the Administrative Simplification provisions of HIPAA.
(To navigate through the slideshow, click anywhere on the screen to advance the slide. To return to a previous slide, right click anywhere on the screen and click on "Previous." To end the slideshow and close your web browser, right click anywhere on the screen and click on "End Show." To end the slideshow and remain on our website, type http://www.hgsa.com in the web address field.

Click here for a HIPAA Educational Article published by the Centers for Medicare and Medicaid Services.

Looking for a Company Approved for X12N 837 4010.A1?

Look no further. Click here for a list of Vendors, Billing Services, and Clearinghouses who were approved for ANSI ASC X12N 837 Professional Format Version 4010.A1 at Highmark Medicare Services. This list will be updated on a weekly basis, so feel free to check it often.

What's the Administrative Simplification Compliance Act (ASCA)?

IMPORTANT: The deadline to file for a one-year extension expired on October 15, 2002. If you did not file for the one-year extension by October 15, 2002, you must be HIPAA compliant now.

The Administrative Simplification Compliance Act allowed covered entities to request a one year extension to the compliance deadline--until October 16, 2003, instead of October 16, 2002--by submitting a compliance plan to the US Department of Health and Human Services. In order to receive the extension, a compliance plan must be submitted by October 15, 2002, by the provider. Your Billing Service and/or Clearinghouse may submit a compliance plan for their company; however, you, as a provider, are still required to submit your own compliance plan, if necessary. Consult with your vendor regarding the date your software/system will be ready in order to determine whether you need to submit a compliance plan.

In an effort to help providers submit a compliance plan, the Centers for Medicare and Medicaid Services developed an electronic form called the HIPAA Model Compliance Plan. CMS urges all covered entities who intend to submit a plan for an extension to do so electronically. Plans submitted electronically will receive a confirmation number as proof of submission; plans submitted on paper via the postal service will not receive a confirmation number.

For assistance completing the electronic form, please refer to the April 15, 2002, Notice issued in the Federal Register; Volume 67, Number 72 (CMS-0007-N).

IMPORTANT: The deadline to file for a one-year extension expired on October 15, 2002. If you did not file for the one-year extension by October 15, 2002, you must be HIPAA compliant now.

Frequently Asked Questions (FAQs)

Questions about HIPAA? Try reading these FAQs for more information: