HIPAA PRIVACY RULEElectronic Transactions Show Issued by Office of the Secretary, Health and Human Services (HHS) According to HHS there are currently about 400 formats for electronic health claims being used in the United States. The lack of standardization minimizes the ability of health care providers and health plans to achieve efficiency and savings. Without government action, a common standard might eventually emerge as the result of technological or market dominance. However, Congress concluded that the
health care industry would benefit if government action were taken to establish industry standards. As a result subtitle F was included in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Through Subtitle F of Title II of HIPAA, Congress required HHS to adopt standards for financial and administrative transactions, and data elements for those transactions, to enable health information to be exchanged electronically. The final rule adopts standards for eight electronic transactions and for code sets to be used in those transactions. The term "code set" is defined to encompass any set of codes to encode data elements. The rule adopts the following code sets as standards:
The CPT and Dental Code may only be used by payment of a royalty. Royalties for electronic use of the CPT are based on a $10.00 per user standard. Royalties for electronic use of the Dental Code in practice management systems are based on $10.00 per user site. Transaction Standards
Prior
approvals have become the standard operating procedure for most hospitals, physicians and other health care providers due to the rapid growth of managed care. Currently, most prior approvals are secured through telephone calls, paper forms or proprietary electronic formats that vary with each health plan. Effective Date The effective date of the rule is October 16, 2000. The impact of the Rule is expected to be in excess of $100 million per year. This means
that Congress will have 60 days after the date of publication in the Federal Register to revise the Rule before it becomes effective. If at the conclusion of the Congressional review process the effective date is changed, the actual effective date will be published in the Federal Register. Each health plan must implement the standards no later than 24 months after adoption. A "small health plan" must implement the standards no later than 36 months after adoption. A "small health
plan" has annual receipts of no more than $5 million (including affiliates). Physicians and other health care providers are subject to the Rule if they wish to do business electronically. If a health care provider is unwilling to upgrade his/her EDI system, the health care provider has the option of using paper claim submissions or a health care clearinghouse. A health care clearinghouse can receive a non-standard format from a health care provider and convert it to a standard
format. Costs and Savings HHS estimates that the estimated gross costs of the Rule will range from $5.8 billion to $7 billion over ten years, and estimates gross savings of $36.9 billion and net savings of 29.7 billion over ten years. HHS
estimates that the net savings to all health care providers over the ten-year period 2002-2011 will be $20.2 billion. The discounted present value of the savings will be $19.1 billion. Of this amount $10.7 billion ($7.7 billion discounted present value) is attributed to savings from claims processing. HHS published proposed privacy standards for electronic health care data on November 3, 1999. (Federal Register Vol. 64, No. 212, pages 59917-60066). It is expected that the final privacy standards will not be published until later this year or next year. What is the most common insurance claim form?The two most common claim forms are the CMS-1500 and the UB-04. These two forms look and operate similarly, but they are not interchangeable. The UB-04 is based on the CMS-1500, but is actually a variation on it—it's also known as the CMS-1450 form.
What is the electronic format of a claim form?Electronic Claim Format
HIPAA requires the submission of all electronic claims using the X12 837 format. HIPAA EDI standards are developed and maintained by the Accredited Standards Committee (ASC) X12.
What is the most common insurance claim form quizlet?The Health Care Financing Administration (HCFA) is the most common insurance claim form.
What is known as is the standard format used by healthcare professionals?The 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically. The Form CMS-1500 is the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed.
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