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HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. HIPAA affects almost the entire health care industry, including employers. For health plans, providers and health care clearinghouses, the critical portions of the act are the Administrative Simplification provisions, which include new standards for electronic transactions that took effect Oct. 16, 2003, as well as regulations on the privacy and security of personal health care information.
The provisions, developed by the U.S. Department of Health and Human Services (HHS), establish national standards for electronic health care transactions and national identifiers for providers, health plans and employers. They also address the security and privacy of protected health information. These standards are intended to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care.
The provisions cover the following:
- Electronic transactions, code sets and identifiers (effective October 16, 2003)
- Privacy of protected health information (effective April 14, 2003)
- Security (effective March 2005)
Payers, healthcare providers and clearinghouses must use specified standards when exchanging these data types in electronic form:
- Claims and claim status
- Remittances (Notice of Payment or Explanation of Payment)
- Authorizations and referrals
HIPAA is a federally mandated law. If providers do not make an effort to become compliant, they will be subject to penalties.
Yes. The Blue Cross NC Companion Guide to EDI Transactions documents any assumptions, conventions, or data issues that may be specific to Blue Cross NC business process when implementing the HIPAA ASC X12N Implementation Guides. The Blue Cross NC Companion Guide consists of one chapter for each transaction type, an introductory chapter for information applicable to all transmissions, and appendices that include Blue Cross NC business edits for health care claims. The Introduction to the Blue Cross NC Companion Guide to EDI Transactions outlines:
- Blue Cross NC business process issues applicable to all transactions
- Interchange Control and Functional Group details
- Reporting Tools (Acknowledgements and Error Reports)
The Blue Cross NC Companion Guide to EDI Transactions is available as pdf files, online at www.bluecrossnc.com/content/providers/edi/hipaainfo.htm.
Blue Cross NC accepts any HIPAA compliant data value within a transaction. However, Blue Cross NC may only process certain values within a given data set. The Blue Cross NC Companion Guide transaction chapters specify those data elements that are required for Blue Cross NC processing. Blue Cross NC believes this is consistent with the regulations of HIPAA, as illustrated by the following portion of the 837 Institutional Health Care Claim Implementation Guide:
837 Health Care Claim Implementation Guide - Section 1.3:
"Payers are required by law to have the capability to send/receive all HIPAA transactions. However, that does not mean that the payer is required to bring that data into their adjudication system. The payer, acting in accordance with policy and contractual agreements, can ignore data within the 837 data set. In light of this, it is permissible for trading partners to specify a subset of an implementation guide as data they are able to 'process' or act upon most efficiently. It behooves trading partners to be clear about the specific data within the 837 they require or would prefer to have in order to efficiently adjudicate a claim."
Direct Senders of electronic transactions will need to do the following:
Complete a copy of the Blue Cross NC Trading Partner Agreement (TPA), available online at www.bluecrossnc.com/content/providers/edi/hipaainfo.htm You need to complete a TPA even if you do not need to test.
- Return an original copy of the TPA, signed by authorized personnel, to Blue Cross NC EDI Services (see Trading Partner Agreement Instructions online for more details.).
Complete an Electronic Connectivity Request (ECR) form for each type of transaction you want to transmit. These ECR forms are available online at www.bluecrossnc.com/content/providers/edi/hipaainfo.htm.
Indirect Senders who transmit electronic transactions to Blue Cross NC via another party (billing service, clearinghouse, or service bureau) will need to do the following:
Complete ECR forms for each type of transaction you want to submit or receive. These ECR forms are available online at www.bluecrossnc.com/content/providers/edi/hipaainfo.htm and may be completed and submitted on your behalf by your clearinghouse or service bureau.
The TPA outlines the roles and responsibilities that bind both Blue Cross NC and its trading partner, to ensure secure electronic transmissions. A TPA is not required by HIPAA, but the ASC Insurance Subcommittee that was charged with developing the Implementation Guides for EDI transactions strongly recommends that trading partners have binding agreements to provide security and assurance in the transfer of electronic information (See Section 1.1.1 of any ASC X12 Implementation Guide). Blue Cross NC has made a business decision to make trading partner agreements a requirement for EDI transmission based on this recommendation.
Blue Cross NC requires the execution of its own TPA with all entities that are sending us direct transmissions. The Blue Cross NC Trading Partner Agreement is comprehensive and should address any issues or legal concerns of our trading partners.
No. However, a newly credentialed practitioner should be assigned a Blue Cross NC Provider Identifier Number by Network Management, another department of Blue Cross NC. Contact your local Network Management field consultant for more information.
You can call the eSolutions HelpDesk at 1-888-333-8594 to verify the status on your Trading Partner Agreement or ECR.
Right now there is only one version of HIPAA compliant transactions in release for transmission. However, as new versions are approved in the future, there will be multiple version options available. Each version will have distinct requirements, so it will be important to identify which version you are transmitting on your ECR form.
If you are company that sends transactions on behalf of health care providers or you are a large provider institution that submits transactions on behalf of multiple provider groups, you will need to identify each group Blue Cross NC Provider ID for which you transmit files. However, you can send all group provider identifiers for which your organization is responsible on one form, using additional sheets of paper if necessary. However, separate forms must be submitted for 837 Institutional Provider Identifiers and 837 Professional Provider Identifiers.
Blue Cross NC has elected to use the TA1 and 997 Acknowledgement transactions to confirm transmissions. These reporting tools are in addition to the traditional Claims Audit Reports that providers are accustomed to receiving for claims submissions. Detailed information about the TA1 and 997 is contained in each transaction chapter of the Blue Cross NC Companion Guide to EDI Transactions, available online at www.bluecrossnc.com/content/providers/edi/hipaainfo.htm.
The HIPAA compliant 997 and TA1 Acknowledgements, as well as the Blue Cross NC Claims Audit Report, are returned to the sender of the transmission. Providers using a clearinghouse or billing service are not likely to use the 997 and TA1. However, all providers should have access to their Blue Cross NC Claims Audit Report. Most clearinghouses collate the proprietary reports of payers for each of their providers and return the reports to the provider in some format, if not the original. If you have not been receiving the Blue Cross NC Claims Audit Report from your clearinghouse, contact them and inquire as to why. It is critical for all providers to use their Claims Audit Report to correct claims that have errors and resubmit those claims electronically.
Providers should also discuss with their clearinghouse how they will be informed when a negative TA1 or 997, involving their data, is received.
Implementation Guide edits address issues such as the presence of required fields or fields required under certain conditions, the validation of data structure (e.g. alpha-numeric requirements, field length), and the correct usage of medical and non-medical code sets. Implementation Guide edits are identified through the TA1 or 997 Acknowledgment transactions.
Blue Cross NC business edits address only those data elements that are required for business processing. For health care claims, our business edits are defined in the context of the 837 transactions in both Chapters 1 and 2 of the Blue Cross NC Companion Guide to EDI Transactions. The Blue Cross NC business edits are also listed in Appendices B and C of the Blue Cross NC Companion Guide to EDI Transactions, available at www.bluecrossnc.com/content/providers/edi/hipaainfo.htm. Business edits are identified by either the Blue Cross NC Claims Audit Report (for 837 Claims filings) or by the paired transaction to a 270, 276, or 278. Those transmitting 834 files are notified of business edits via phone or email.
You need to speak to your vendor/clearinghouse about this issue. Blue Cross NC is not providing alternative reporting tools to the TA1 and 997 Acknowledgements.
The TA1 Acknowledgement is returned immediately upon receipt of the transmission. Senders should expect to see the TA1 within 5 minutes. The 997 Acknowledgement is also generated immediately, but because the 997 can vary in length, it may take slightly longer. The Claims Audit Report is generated nightly, reflecting all claims that were transmitted by 4:45 p.m. that business day, and received by senders the next business day by 8:00 a.m.
Yes. Both the 997 and TA1 Acknowledgement include the acronym "ACK" in the file naming convention so that these files are immediately recognizable. In addition, transaction files include the transaction number in the file name. The 271, 277, 278, and 835 include those numbers in the file name. As in the past, senders receive their Batch ID's when they receive the EDI Production Services Notification Letter confirming their connectivity and readiness date.
Generally, the percentage of claims requiring additional medical notes for processing is small. When such claims appear, providers are contacted, via letter, when that information is needed. Providers who want to send additional medical notes information should use the NTE Segment of the 2300 Loop in the 837 electronic claim. Providers should NOT send unsolicited medical notes on paper as they cannot be attached to the electronic claim.
Blue Cross NC requires that secondary claims be filed after primary claims have been processed and posted to the provider's practice management system. The 837 Health Care Transactions provide for COB claims data, and secondary claims should be submitted by batch transaction, just as primary claims are submitted. The 2320 Loop of the 837 contains all COB (Coordination of Benefits) information.
No, if the secondary claim is filed electronically in the 837 format and includes the primary payment information, you do not need to supply a paper EOB.
Yes, WebMD must complete the Blue Cross NC Electronic Connectivity Request (ECR) form with the provider's identifying information and authorized signature before electronic set-up can be completed.
Blue Cross NC invokes security validation edits to ensure that only authorized trading partners and providers are exchanging data with Blue Cross NC. Security validation takes place at both the ISA (Interchange) and GS (Functional Group) Levels of the transmission, as well as the ST (Transaction Set) Level of the transmission.
What portion of the transmission gets rejected depends upon where the violation occurs. If the violation is in the ISA, the entire transmission fails. If it is in the GS portion, the entire Functional Group fails. If a security violation occurs within the Transaction Set, all claims/inquiries associated with the same Provider Identifier that could not be validated fail. See individual chapters of the Blue Cross NC Companion Guide to EDI Transactions for more information.
Yes. File State Health Plan claims as you would any other.
Mental health claims should be filed directly with Blue Cross NC. Claims for Blue Medicare and commercial HMO members for dates of service with a start date prior to January 1, 2020 should be submitted to Magellan. Call the provider Blue line with questions at 1-800-214-4844.
In the past Blue Cross NC manually revised many paper and electronic claims containing faulty data when the error involved identifiable data elements that we were able to correct. However, given changes mandated by HIPAA, Blue Cross NC no longer allows the manual changing of identification numbers, dates of service, place of service, diagnosis codes, procedure codes, or provider numbers. Claims submitted with these errors will be subject to all HIPAA Implementation Guide edits and Blue Cross NC business edits and will be returned to the provider for correction.
Taxonomy codes are not required for Blue Cross NC adjudication. The PRV segment (Loop 2000A) is not required for Blue Cross NC processing.
Business edits are specific to each payer. Blue Cross NC provides tables with its Business Edit Codes in Appendices B and C of the Blue Cross NC Companion Guide to EDI Transactions, available online at www.bluecrossnc.com/content/providers/edi/hipaainfo.htm.
Claim Status Codes, which include codes for denials, exist for the 835 Remittance/Payment Advice (CLP Segment) and the 277 Claim Status Response (STC Segment). These codes are common to all payers.
E-Codes, used for Institutional Claims, are accepted but not required for Blue Cross NC processing.
Blue Cross NC cannot over-rule any requirement from the HIPAA Implementation Guides (IG). If an Implementation Guide states that data is required, it must be included in the transaction. In the example given, transaction would be rejected prior to any Blue Cross NC processing because it would not pass the Implementation Guide edits.
Providers should work with their software vendors and business personnel to ensure that required data is being collected and maintained in their practice management systems.
Blue Cross NC now requires that membership identification numbers be submitted exactly as they appear on the Membership ID Card. Membership Identification Numbers for Blue Card and Federal Employee Plan members may or may not include suffixes. Transactions for these plan members are routed through Blue Exchange. You will continue to see a request for the exact membership ID numbers if the number cannot be validated.
If the HIPAA Implementation Guide requires a segment or element, you must include it in the transaction, even if Blue Cross NC does not need this data to process the claim. Include the service codes when filing your 837 Professional Claims to ensure your transaction passes the Implementation Guide edits.
Yes, both claim status and edibility information for out-of-state claims and members are available. Blue e transmits your inquiries to the Blue Cross and Blue Shield home plan of your patient and returns their response.
Batch 837 Health Care Claims can no longer be corrected on Blue e. A new error listing on Blue e identifies of the 837 errors - the 837 Claim Denial Listing. Providers should correct claims in error on their practice management systems and resubmit those claims in a batch 837 Health Care Claim transactions. Batch claims are processed daily in the evening. As soon as the corrected claims are processed and successfully adjudicated, they are dropped from the Blue e Error Listing.
Blue e services are available for both the local proprietary format and HIPAA compliant transactions. Blue e is available for direct data entry of claims, claim correction, and inquiries in the Blue Cross NC local proprietary format and will continue to be available for as long as the CMS contingency plan is in place and the local proprietary format can be accepted.
Blue e is available for eligibility inquiries and inquiries about 837 claims submitted in batch to Blue Cross NC; however, the claims correction functionality on Blue e is not available for HIPAA compliant 837 claims.
The error correction functionality of Blue e is not available for claims submitted in the HIPAA-compliant 837 format, but will be available for those claims submitted on Blue e or in batch local proprietary format. Blue e claim correction functionality is being removed in the HIPAA compliant format to encourage providers to make corrections to claims on their practice management systems and resubmit claims in electronic batch.
Blue Cross NC continues to provide Blue e and RealMed services and support them.
HIPAA Privacy regulations have demanded greater care in the protection of customers' Personal Health Information (PHI). As a consequence, membership identification numbers, along with other member data, submitted for inquiries or claims must match Blue Cross NC system data before they can be accepted and processed. Different Blue plans have different prefix and/or suffix formats (or none at all). If the submitted membership ID exactly matches that of the ID number as presented on the membership ID card, the membership ID number will be recognized.
Blue Exchange, the data management system shared with Blue Cross and Blue Shield plans around the country, has been available for HIPAA compliant transactions since August of 2003. Transactions that have been routed through Blue Exchange are already receiving acknowledgements and responses.
Responses from Blue Exchange are in 'real-time' – usually within seconds, depending on the response time of the plan to which it was sent. Users can access the Summary Results pages to retrieve responses from other Blue plans.
Yes. However, you must complete an 835 Electronic Connectivity Request form if the vendor handling the 835 is different from the vendor handling your 837 Claims.
All paired transactions (the 271, 277, 278-11) are returned to the sender of the initiating transaction (the 270, 276, 278-13). The 835 is returned either to the sender of the 837 OR to the entity identified on the 835 Electronic Connectivity Request form if it should be returned to an entity other than that which transmitted the 837.
No. Only direct senders of transmissions need to test with Blue Cross NC. If you are using a clearinghouse billing service, or software from a vendor that has tested, you do not need to test with Blue Cross NC.
Blue Cross NC cannot tell you if your clearinghouse or billing service has begun testing. Contact them directly.