• General
• Coding
• Remittance Advice (Explanations of Payment)
• Managed Care
• Claim Software Vendors and Clearinghouses
• Provider Numbers and Enrollment
• Future Issues

A: (3/2002) The purpose of the administrative simplification provision of HIPAA is to standardize EDI in the health care industry overall.  There are currently over 400 electronic claim formats within the health care industry.  HIPAA standards will help create a more uniform mechanism for electronic communication.  Health care plans, including Medicaid and Medicare, may require some situational data elements that other health plans do not.  Policy and billing requirements will still be directed by each health plan.  Be aware that changes to standardize and promote electronic data exchange may require health plans to also modify the information requirements for paper claims.

A: (3/2002) The provider taxonomy is a code set that identifies a health care provider by type and specialty.  A provider may have more than one taxonomy code, depending on the type of service rendered.  The taxonomy is a required data element on the 837 Institutional, 837 Professional, and 278 transactions.  The taxonomy code is not a UPIN, Medicare provider number, or Medicaid provider number.  The following is an example of the taxonomy code for a FQHC:

FQHC - 261QF0400N

- 26 - Ambulatory Health Care Facilities
- 1Q - Clinic/Center
- F0400 - Federally Qualified Health Center
- N - 'No' to national education requirement

The full provider taxonomy code set can be found at www.wpc-edi.com/taxonomy/Codes.html.

A: (3/2002) WEDI is the acronym for Workgroup for Electronic Data Interchange.  WEDI works with the implementation of EDI in the health care industry.  For more information, visit their web site at www.wedi.org/.

A: (3/2002) HIPAA regulations do not mandate billing requirements, such as what provider types or services are billed on a specific transaction.  The regulations will afford health plans and payers significant flexibility in how they administer programs.  HIPAA does, however, mandate the elimination of local codes, which the IHCP uses for billing ambulance and other services.  Payment policies will not change due to HIPAA requirements, but how providers bill for certain services is likely to change.  Any future changes to the IHCP billing guidelines will be communicated to providers through future publications.

A: (3/2002) HIPAA does not require providers to submit claims electronically.  Paper claims will continue to be accepted.  However, the IHCP encourages the use of electronic claim submission and remittance advice (RA) receipt.

A: (3/2002) These forms will not become obsolete.  However, the OMPP is reviewing all claim forms to determine if, and what, modifications may be recommended with the implementation of HIPAA.  Some current IHCP claim field requirements may need to be modified for HIPAA resulting in changes to reference the data requested for both electronic and paper claim data submissions.

A: (3/2002) No.  Currently, the IHCP does not anticipate running two versions of IndianaAIM.  For this reason, paper claim forms may be modified to be very similar to the 837 and NCPDP transaction required data elements.  The IHCP, EDS, and HCE are currently reviewing the need for paper claim form revisions, and additional information on any decisions for change will be forthcoming.

A: (3/2002) No.  EDS will not use a clearinghouse for claim processing purposes, but will continue to maintain IndianaAIM after modification to support HIPAA requirements.

A: (3/2002) No.  The current paper prior authorization (PA) process will be maintained for providers and situations when the electronic 278 transaction is not feasible.  By adding the electronic capability, the IHCP will be adding an additional alternative to the PA process to comply with HIPAA requirements

A: (3/2002) Yes.  There may, however, be changes to the available information and information necessary for access.  The IHCP will provide updates about changes to all of the EVS once finalized.

A: (3/2002) For the HIPAA compliance date, we do not anticipate that Form 8A will be an electronic attachment.  The IHCP, in conjunction with Medicaid agencies across the country, is developing standard claim attachments and is working with the HIPAA transaction developers to incorporate Medicaid attachment needs.  Electronic claim attachment information for the IHCP will be published as national standards are approved and released.

A: (3/2002) HIPAA regulations do not determine the implementation of the ICD-10 codes.  No information has been published to date that eliminates the eventual updating of this coding system.

A: (3/2002) Yes, for electronic claim submission.  The DSM-4R codes are not named in the August 17, 2000, Transaction and Code Set final rule as a HIPAA-required code set and will not be used for diagnosis coding on any electronic transactions.  Also, the IHCP does not recognize the DSM-4R codes for any paper transaction, such as a paper claim or PA requests.  This policy will not be changing.  Note that the DSM-4R manual states, "…codes and terms in the DSM-4R are fully compatible with ICD-9-CM."  All diagnoses must be submitted with an International Classification of Diseases (ICD-9-CM) diagnosis code from Volumes 1 and 2.  It is true that the ICD-9-CM does not include diagnostic criteria and multi-axial system coding, but these are not used for actual claim submission.

A: (3/2002) Yes.  The IHCP, EDS, and HCE are actively working to replace all W, X, Y, and Z procedure codes, modifiers, and occurrence codes used today in the IHCP.  The IHCP and other states are participating in National Medicaid EDI HIPAA Workgroup and local code subgroup meetings with HCE and EDS.  This subgroup is focusing on identifying the Indiana Medicaid local codes that do not have a match within the national code sets.  The subgroup will also identify possible solutions, such as modifiers or taxonomy, and develop formal recommendations to the CMS as to what codes must be added at the national level to meet Medicaid needs.  Specific information about the local code to national code designation crosswalk will be published in the future.

A: (3/2002) The August 17, 2000 HIPAA Transaction and Code Sets final rules named the National Drug Code as the required code set for reporting all drugs and biologics on all HIPAA transactions.  The IHCP plans to require NDC use in billing the 837 transactions.  Further information will be published by the IHCP about any policy revisions as they become available.

A: (3/2002) As noted in a previous response, the IHCP, EDS, and HCE are currently reviewing paper claims for applicability to meet HIPAA needs.  Information about this topic will be published upon finalization.

A: (3/2002) The 835 transaction, which replaces the current electronic RA, uses the standard Claim Adjustment Reason Code set and Remittance Remark Code set.  These code sets will replace the IHCP EOB codes on the electronic 835 transaction.  At this time, the IHCP plans to generate a paper RA to all providers that contains the current IHCP EOB codes.  This paper version will assist providers in understanding the Claim Adjustment Reason Code and Remittance Remark Code usage, and will also assist in determining the appropriate reason for claim denial.

A: (3/2002) We do not anticipate removing the use of certification codes with the HIPAA changes.

A: (3/2002) If the MCO meets the requirements for a covered entity, yes, the MCO must comply.  According to the definition found in the Federal Register, Volume 65, No. 160, page 50318, the state Medicaid plan contracts with an MCO to provide services to Medicaid members.  The MCO in turn contracts with health care providers to render these services.  The MCO is then considered a health plan.  All providers, health plans, and clearinghouses that transmit or store electronic data must comply.

A: (3/2002) Under HIPAA, procedure codes will be released quarterly through the CMS.  The OMPP, EDS, and HCE are working on a plan to help ensure that all code sets, valid for the health care service date, are available through IndianaAIM for provider and MCO use.

A: (3/2002) At this time, the OMPP anticipates that all shadow claims, also known as encounters, will be required to be submitted on the standard format named in the August 17, 2000, rule.  For example, the professional health care service encounter will be submitted from the MCO to EDS via the 837 professional encounter transaction.  By using the 837 transactions for shadow (encounter) claim reporting, MCOs have the capability to report shadow claim adjustments electronically.

A: (3/2002) The health care clearinghouse must comply with the standards outlined in the August 17, 2000, rule.  There are additional requirements specific for clearinghouses found in 45 CFR 162.923 (c) (1-2) and 45 CFR 162.930.  Requirements found at 45 CFR 162.923 outline the requirements for covered entities.  It is the provider's responsibility to verify the compliancy of the clearinghouse contracted, as the clearinghouse is acting as an agent for the provider.

A: (01/2003) Please read the Trading Partner pages for more information

A: (3/2002) The covered entity, such as a provider, can use a health care clearinghouse to conduct the transactions as named in the final rule.  Again, review the requirements found at 45 CFR 162.923, which outline the requirements for covered entities.  It is the provider's responsibility to verify the compliancy of the clearinghouse contracted as they are acting as an agent for the provider.

A: (11/2002) Trading Partner information is now available on this web site.  This information includes IHCP specific companion guides for each transaction.  The national X12N transaction HIPAA implementation guides are available on the Washington Publishing Company Web site www.wpc-edi.com/hipaa/HIPAA_40.asp.  Consult the NCPDP Web site for the NCPDP transaction standards used for retail pharmacy services.  The NCPDP Web site can be found at www.ncpdp.org.

A: (3/2002) The proposed National Standard Health Care Provider Identifier rule identifies two possible mechanisms for the NPI assignment.  We are awaiting publication of the final rule before determining what changes are required to the IHCP provider enrollment and IHCP provider number assignment.

1. Health plans cannot reject transactions; how does this correspond with privacy?
2. Does the NPI for the provider do away with the UPIN number? Provider number? Etc?
3. With the NPI number, we are a home care agency; will NPI supersede all our numbers?
4. What about the UPIN number?
5. All providers will have one number (NPI); will that affect our ID number for Medicaid and Medicare?
6. We have several locations, with one number (NPI); will this number have an A, B, or C?
7. How can a facility have one NPI when we are a specialty hospital? For example, a hospital with multiple locations, campuses, and specialties.