HIPAA Standards for Electronic Healthcare Transactions
HIPAA required the Department of Health and Human Services (HHS) to adopt national standards for electronic healthcare transactions. All covered entities must comply with the electronic transactions and code sets standards adopted by HHS.
Covered entities under HIPAA include:
- Health plans
- Healthcare providers who transmit health information in electronic form in connection with a transaction covered by HIPAA
- Healthcare clearinghouses
The electronic healthcare transactions covered under HIPAA that may affect provider organizations include:
|Transaction Description||HIPAA Transaction Standard||SWH Readiness Status|
|Claims or Encounter Information||ASC X12N 837 Professional, or Institutional Healthcare Claims and Encounters||Implemented|
|Eligibility for a Health Plan||ASC X12N 270/271 Healthcare Eligibility Benefit Inquiry and Response||Implemented|
|Referral Certification and Authorization||ASC X12N 278 Healthcare Services Review - Request for Review and Response||Implemented|
|Claims Status||ASC X12N 276/277 Healthcare Claim Status Request and Response||Implemented|
|Payment and Remittance Advice||ASC X12N 835 Healthcare Claim Payment/Advice||Implemented|
IMPORTANT NOTE: HIPAA does not require healthcare providers to conduct the above transactions electronically with Senior Whole Health of New York. For example, if you currently submit claims to Senior Whole Health of New York using paper, you may continue to do so.
Affordable Care Act
The Patient Protection and Affordable Care Act - HR 3590, also called the “Affordable Care Act” was enacted on March 23, 2010. The Affordable Care Act (ACA) includes provisions related to administrative simplification (Sec. 1104) and standards for financial and administrative transactions (Sec. 10109). It calls for the National Committee on Vital and Health Statistics (NCVHS) to provide input into the process of rulemaking for the establishment of a unique health plan identifier and to provide advice and recommendations to the Department of Health and Human Services (HHS) relative to Operating Rules for electronic exchange of information not defined by a standard or its implementation specification. Operating Rules development shall be conducted by a qualified nonprofit entity that meets specific requirements.
Pursuant to ACA, the Secretary of HHS has adopted the below Operating Rules:
|Adoption of operating rules||Effective Date||SWH Readiness Status|
|Eligibility for a health plan and health claim status||January 1, 2013||Implemented|
|Electronic funds transfers and health care payment and remittance advice||January 1, 2014||Implemented|
|Health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, and referral certification and authorization||TBD||Awaiting Final Rule|
How to get started exchanging HIPAA transactions with Senior Whole Health of New York
Review SWH's EDI Website and follow the steps indicated.
HIPAA Implementation Guides
HIPAA ANSI X12 Transaction Standards can be downloaded from the www.wpc-edi.com website.
Contact the HIPAA Help Team:
HIPAA Transactions testing and enrollment
If you are a provider and have a concern or complaint regarding Senior Whole Health of New York’s HIPAA Transaction Code Sets compliance or any other HIPAA issue call our HIPAA Provider Hotline toll free at 1-866-MOLINA2 (1-866-665-4622) or email us at HIPAAMailbox@MolinaHealthcare.com.
General HIPAA Questions or Comments:
Contact Senior Whole Health of New York's HIPAA Program Office as listed in the Contact HIPAA section below:
For general business questions: Please contact your Senior Whole Health of New York provider services representative