According to the Centers for Medicare and Medicaid Services, “HIPAA required HHS to establish national standards for electronic transactions to improve the efficiency and effectiveness of the nation's health care system.”
These standards, known as the adopted standards, apply to all HIPAA-covered entities, including health plans, healthcare clearinghouses, and healthcare providers who conduct electronic transactions.
Understanding the adopted standards
HIPAA has mandated the adoption of specific standards for electronic healthcare transactions, ensuring a consistent and interoperable framework across the industry. These standards, developed by various accredited standards development organizations, serve as the foundation for seamless data exchange and efficient administrative processes.
Transactional standards
The adopted standards for electronic healthcare transactions cover a wide range of activities, from claims submission to eligibility verification and payment processing. These standards, outlined below, provide a standardized format for the exchange of information between different entities within the healthcare ecosystem.
- Health claims (institutional, professional, and dental): ASC X12N 837 Version 5010
- Eligibility and benefit verification: ASC X12N 270/271 Version 5010
- Prior authorization and referrals: ASC X12N 278 Version 5010
- Claim status inquiry and response: ASC X12N 276/277 Version 5010
- Claim payment (or EFT, electronic funds transfer): ACH CCD+Addenda, ASC X12N 835 Version 5010
- Electronic remittance advice (ERA): TRN Associated Trace Number, ASC X12N 835 Version 5010
- Coordination of benefits: ASC X12N 837 Version 5010
- Referral certification: ASC X12N 278 Version 5010
- Retail pharmacy drug claim submission: NCPDP D.0
- Medicaid pharmacy subrogation: NCPDP 3.0
- Enrollment/disenrollment in a health plan: ASC X12N 834 Version 5010
- Premium payment/explanation (employer): ASC X12N 820 Version 5010
Code set standards
In addition to the transactional standards, HIPAA has also mandated the use of specific code sets for various healthcare-related activities. These code sets ensure a consistent and standardized approach to data representation, facilitating seamless data exchange and reporting.
- Diagnosis coding: ICD-10-CM - International classification of diseases, 10th edition, clinical modification
- Hospital inpatient procedure coding: ICD-10-PCS - International classification of diseases, 10th edition, procedure coding system
- Outpatient procedure and physician services coding: CPT - Current procedural terminology
- Supplies/not included in CPT: HCPCS - Healthcare common procedure coding system
- Dental procedure coding: CDT - Code on dental procedures and nomenclature
Federally mandated operating rules
While the adopted standards provide a framework for electronic transactions, HIPAA also requires the implementation of federally mandated operating rules. These rules, developed by the Council for Affordable Quality Healthcare (CAQH) CORE, try to enhance the consistency and efficiency of the transaction exchange process.
The following transactions have federally mandated operating rules:
- Eligibility and benefit verification: ASC X12N 270/271 Version 5010 (Compliance date: January 1, 2013)
- Claim status inquiry and response: ASC X12N 276/277 Version 5010 (Compliance date: January 1, 2013)
- Claim payment (or EFT, electronic funds transfer): ACH CCD+Addenda, ASC X12N 835 Version 5010 (Compliance date: January 1, 2014)
- Electronic remittance advice (ERA): TRN Associated Trace Number, ASC X12N 835 Version 5010 (Compliance date: January 1, 2014)
These operating rules establish a common set of requirements for the implementation and use of the adopted standards, ensuring a more streamlined and consistent experience for all participants in the healthcare ecosystem.
The significance of adopted standards and operating rules
HIPAA-adopted standards and operating rules have a profound impact on the healthcare industry, driving advancements in data management, administrative efficiency, and patient care.
Improved data exchange and interoperability
Establishing a common set of standards for electronic transactions, HIPAA has facilitated the seamless exchange of data between different healthcare entities. Interoperability has enabled more efficient data sharing, reducing the administrative burden and improving the quality of patient care.
Enhanced administrative efficiency
Standardized transaction formats and operating rules has streamlined administrative processes, such as claims submission, eligibility verification, and payment processing. These improvements have resulted in reduced processing times, fewer errors, and lower operational costs for healthcare organizations.
Strengthened data security and privacy
HIPAA's emphasis on data security and privacy has driven the adoption of standards and operating rules. Ensuring the consistent and secure transmission of sensitive healthcare information has helped protect patient confidentiality and maintain the integrity of the healthcare system.
Compliance and regulatory oversight
The HIPAA-mandated standards and operating rules have created a more structured and accountable healthcare ecosystem. Adhering to these regulations is mandatory for healthcare organizations, with failure leading to significant penalties and regulatory scrutiny. Such a compliance environment has helped ensure consistent and responsible use of healthcare data.
FAQs
Does HIPAA apply to adopted standards and operating rules?
HIPAA applies to all HIPAA-covered entities, including health plans, healthcare clearinghouses, and healthcare providers who conduct electronic transactions. Any provider who accepts payment from any health plan or other insurance company must comply with HIPAA if they conduct the adopted transactions electronically.
Do I need consent for adopted standards and operating rules?
HIPAA requires covered entities to have written agreements to ensure their business associates comply with the regulations. Examples of business associates include clearinghouses and independent medical transcriptionists. These written agreements keep all parties involved in the electronic transactions compliance process.
What can I use for adopted standards and operating rules?
Healthcare organizations can use the resources and guidance provided by the Centers for Medicare & Medicaid Services (CMS) to navigate the HIPAA regulations, including detailed information on the adopted standards, operating rules, and compliance timelines. By staying informed and proactive, these organizations can ensure seamless operations and patient care while maintaining compliance with the HIPAA framework.
Learn more: HIPAA Compliant Email: The Definitive Guide
Farah Amod
