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The 1996 Health Insurance Portability and Accountability Act (HIPAA), as amended, establishes standards and requirements for health plans, clearinghouses, and healthcare providers—including MTFs—that transmit health information electronically. This can be via claims, remittance, eligibility, and claims status requests and responses. Implementing regulations issued by the Department of Health and Human Services (HHS) have established requirements for: (a) standard transactions, code sets and identifiers to be used when transmitting HIPAA-compliant transactions; (b) information security guidance; and (c) protecting patient confidentiality. More information on HIPAA privacy and security requirements is available at http://www.tricare.mil/tma/privacy/default.aspx.

HIPAA Electronic Transaction Standards, Code Sets and Identifiers

In the HIPAA regulations, the Secretary of HHS adopted certain standard transactions, code sets and identifiers required for the electronic data interchange (EDI) of health care data.

More information on HIPAA transactions, code sets, and identifiers is available:

HIPAA-Compliant Electronic Claims

Electronic claims are transmitted in data “packets,” also referred to as loops and segments, from MTFs through clearinghouses to payers. Billing solutions first apply an initial set of edits, commonly known as front-end edits or pre-edits, to prepare claims for electronic clearinghouses. The clearinghouses ensure that the claims meet the basic format and content requirements of the HIPAA standards. If errors are detected at this level, a single claim or the entire batch would be rejected for correction and resubmission. Claims that pass through the clearinghouses are processed by the payers' claims-processing systems. Additional payer edits may include compliance with payer coverage and payment policy requirements. Edits at this level as well could result in rejection of individual claims for resubmission, determination of allowed amounts as well as payer and patient responsibility, or denial of the claim. In each case, the MTF should be sent a response that indicates the error to be corrected or the reason for payment adjustment or denial. After successful transmission, an acknowledgement report should be transmitted back to the MTF.

More information on HIPAA is available in the UBO User Guide.

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