HIPAA Transactions: A Nontechnical Business Guide for Health Care Book

Dedication
Foreword
Acknowledgments
About the Authors
How to Use This Book
Introduction
CHAPTER 1 Achieving Success with Transactions
The Big Picture of HIPAA Transactions
The Nuts and Bolts of Administrative Simplification
Building the Infrastructure
Four Sets of Standards
The HIPAA Transactions Rule
The Claims Process: Paper and Electronic Environments
Benefits of HIPAA Transactions and Code Sets
Summary
CHAPTER 2 The Business of HIPAA Transactions
The HIPAA-Compliant Transaction
Types of HIPAA Transactions and What They Mean
Planning for HIPAA Transactions
Building the Implementation and Compliance Plan
The Certification and Testing Process
What You Should Know About Testing
What You Should Know About Certification
Business Challenges
Billing Cycles
Staff Acceptance
Implementation Guides
Trading Partner Agreements
Health Plan-Specific Information
Payer Companion Guides
Enforcement
Enforcement Will Be Complaint-Driven
Covered Entities Can Submit a Corrective Action Plan or Demonstrate Compliance
More HIPAA Transactions to Come
CHAPTER 3 A Case Study Through HIPAA Transactions
Case Study
Eligibility Inquiry (The 270)
What the 270 Will Do For You
Challenges
Eligibility Response (The 271)
What the 271 Will Do For You
Challenges
Level 1 Response
Level 2 Response
Level 3 Inquiry
Inquiry Errors
Health Care Claims/Encounters (The 837)
What the 837 Will Do For You
Challenges
How to Use the 837P
Section 1: Billing/Pay-to ProviderInformation
Section 2: Information About the Patient and Payer
Section 3: Claim Information
Section 4: Service Line Information
Remittance Advice (Claim Payment) Transaction (The 835)
What the 835 Will Do For You
Challenges
Transaction Summary
Corrections or Reversals
Claim Status Transactions (The 276)
What the 276 Will Do For You
Challenges
Information You ll Need for a Claims Status Inquiry
Service Line Information
Claim Status Response (The 277)
Category Codes
Status Codes
Entity Codes
Authorization/Referrals (The 278)
What the 278 Will Do For You
Challenges
Request
Response
HIPAA Transactions Summary
CHAPTER 4 The Importance of Code Sets
An Overview of Code Sets
Code Sets in the Physician s Office
Code Set Categories
Medical Data Code Sets
Nonmedical Data Code Sets
How to Read Code Sets
External Code Sets
Internal Code Sets
CHAPTER 5 Implementation Guides Primer
Transaction Standards Revisited
Structure of the Implementation Guides and Addenda
First Things First
Trading Partner Agreements
Required vs Situational Data Elements
Batch vs Real Time Transactions
Loops
Transaction Set
Data Segment
Data Element
Structure of the ASC X12N Standard Transaction
Control Segment Structure
Transaction Sets
The 270 Eligibility Benefit Inquiry Transaction Set
Example of an Eligibility Inquiry
CHAPTER 6 Cost, Price, Value, and Return on Investment
Financial Assessment Tools
You and Your Electronic Investment
A Little Subjective History
The 1960s
The 1970s
The 1980s
The 1990s
The 2000s
Implications of This Odyssey
Looking Ahead: An Uncertain Health Care Environment
Size and Complexity of US Health Care Market
Potential Market Disturbances: Paradigm Shifts
Reinventing Your Future
The Next Big Thing
Electronic Medical Record
Debit Card
Appendix
Helpful resources. . . .
Guidance on Compliance with HIPAA Transactions and Code Sets, July 24, 2003
Transcript from CMS HIPAA Roundtable, Sept. 25, 2003
Electronic Submission of Medicare Claims Interim Final Rule
Transactions and Code Sets Interim Final Rule, Medicare Program: Electronic Submission of Medicare Claims
Implementation of the Telecommunication or Batch Standard
Check for Understanding Self Test
Glossary
Index