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Transaction
and Code Sets Standard/Rule (HIPAA)
Health
Insurance Portability and Accountability Act (HIPAA) regulations
are divided into four Standards or Rules: (1) Privacy,
(2) Security,
(3) Identifiers,
and (4) Transactions and Code Sets (TCS). The
TCS Standard/Rule was first released in August 2000 and updated
in May 2002; it took effect on 16 October 2003 for all covered
entities.
(Normally, small
covered entities have one year more than their large colleagues.
However, the Administrative Simplification Compliance Act
(PL107-105) provided a one-year extension for large covered
entities that submitted a compliance plan by 15 October 2002.
Small entities were not provided with an extension opportunity.
For other rule dates, see the HIPAA
compliance calendar.)
Regulations associated
with the TCS Rule mandate uniform electronic interchange formats
for all covered entities. It is this standardization -- along
with the introduction of uniform identifiers for plans, providers,
employers and patients under the Identifier Rule -- that is
expected to produce the lion's share of the efficiency savings
of "administrative
simplification."
Unlike the HIPAA
Privacy Rule, which applies
to protected health
information (PHI) in "any form or medium," the
TCS Rule covers only PHI in electronic form. (Perhaps it is
self-evident that an electronic format standard could apply
only to electronically-rendered information. However, this
"electronic focus" is true of the HIPAA Identifier
and Security rules as well. For more information, see the
discussion of electronic
applicability under the Security Rule.)
While many entities
in the health sector have developed, or are in the process
of developing, electronic data interchange (EDI) standards,
the consensus remains that "the lack of common, industry-wide
standards [is] a major obstacle to realizing potential efficiency
and savings." (Final TCS Rule, p.3) Hence HIPAA allows
the US Department of Health
and Human Services (DHHS) to select the best of these
efforts and require their use by all covered entities.
The TCS Rule has
selected its standards from among the preexisting transaction
and code set specifications of a variety of non-governmental
designated standards maintenance organizations
(DSMOs). The DSMOs retain the primary responsibility for
updating their standards as evolving health sector needs dictate.
(The Secretary of DHHS may at any time pick an alternative
to those from DMSOs if it will substantially reduce administrative
costs. But any new standard must be promulgated using formal
rulemaking procedures, including appropriate time for notice
and comment.)
At present, the
TCS Rule encompasses the following standard electronic transaction
formats -- preponderantly derived from the ANSI
X12N standards:
- Health Care
Claims or equivalent encounter information (X12N 837);
- Eligibility
for a Health Plan (X12N 270/271);
- Referral Certification
and Authorization (X12N 278 or NCPDP
for retail pharmacy);
- Health Care
Claim Status (X12N 276/277);
- Enrollment and
Disenrollment in a Health Plan (X12N 834);
- Health Care
Payment and Remittance Advice (X12N 835);
- Health Plan
Premium Payments (X12N 820); and
- Coordination
of Benefits (X12N 837 or NCPDP for retail pharmacy).
Copies of the detailed
implementation specifications for each X12N standard may be
downloaded
for free. (Note, however, that each one runs several hundred
pages.)
Within these transactions,
the standards for coding information include:
See also:
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