HIPAA Compliance

HIPAA mandates, the Healthcare Market and TIE Commerce

Payers, providers, and intermediaries need to communicate electronically.

Healthcare is a complicated industry and the government has not made it any easier with the passage of the Healthcare Insurance Portability and Accountability Act. There is one certainty from this legislation – much more than 25% of the healthcare industry will be communicating via electronic commerce. The HIPAA mandates have forced everyone in the healthcare network to examine ways to communicate using some form of eCommerce, whether that is EDI or XML. Payers, providers, and intermediaries are currently using TIE to reduce costs and streamline functions from enrollment to claims processing.

TIE Products/Services Provide:

Connection to healthcare network players:

- From desktops to VANs,from networks to the Internet.
- Flexible enough to accommodate most computing environments.
- Data transformation into HIPAA standards for trading partner transactions.
- Expands your markets and assures you’ll meet HIPAA requirements.
- Integration across multiple systems and databases.
- Greater efficiencies and information sharing within your organization and out to your partners.
- Simple relationship mapping.
- Saves times building new transactions and partner relationships
- An unprecedented feature of TIE products.
- Support HIPAA syntax and transactions.
- Validation of standards insures accuracy and compliance.

 

Types of HIPAA Standards Supported by TIE

HIPAA 270 Eligibility, Coverage or Benefit Inquiry:

This Draft Standard for Trial Use contains the format and establishes the data contents of the Eligibility, Coverage or Benefit Inquiry Transaction Set (270) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to inquire about the eligibility, coverages or benefits associated with a benefit plan, employer, plan sponsor, subscriber or a dependent under the subscriber's policy. The transaction set is intended to be used by all lines of insurance such as Health, Life, and Property and Casualty.

HIPAA 271 Eligibility, Coverage or Benefit Information:

This Draft Standard for Trial Use contains the format and establishes the data contents of the Eligibility, Coverage or Benefit Information Transaction Set (271) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to communicate information about or changes to eligibility, coverage or benefits from information sources (such as- insurers, sponsors, payors) to information receivers (such as - physicians, hospitals, repair facilities, third party administrators, governmental agencies). This information includes but is not limited to: benefit status, explanation of benefits, coverages, dependent coverage level, effective dates, amounts for co-insurance, co-pays, deductibles, exclusions and limitations.

276 Health Care Claim Status Request:

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim Status Request Transaction Set (276) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used by a provider, recipient of health care products or services, or their authorized agent to request the status of a health care claim or encounter from a health care payer. This transaction set is not intended to replace the Health Care Claim Transaction Set (837), but rather to occur after the receipt of a claim or encounter information. This request may occur at the summary or service line detail level.

277 Health Care Claim Status Notification:

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim Status Notification Transaction Set (277) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used by a health care payer or authorized agent to notify a provider, recipient, or authorized agent regarding the status of a health care claim or encounter or to request additional information from the provider regarding a health care claim or encounter. This transaction set is not intended to replace the Health Care Claim Payment/Advice Transaction Set (835) and therefore, will not be used for account payment posting. The notification may be at a summary or service line detail level. The notification may be solicited or unsolicited.

835 Health Care Claim Payment/Advice:

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim Payment/Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution.

837 Health Care Claim:

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.

For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance.