Critical Path Network: Take a deep breath, now prepare for EDI deadline

Testing already should have begun

Just as health care managers take a breath after rushing to make sure their hospitals are in compliance with the privacy standard, it’s time to kick into gear for the upcoming Health Insurance Portability Accountability Act (HIPAA) transaction code-set deadline, which is Oct. 16, 2003.

The HIPAA transaction standard establishes the content and format to be used in the electronic submission of claims and other administrative data between health care entities, including providers and health plans.

Although that deadline is a few months away, Gillian Cappiello, CHAM, senior director for access services and chief privacy officer at Swedish Covenant Hospital in Chicago, points out that hospitals were to begin testing their electronic data interchange (EDI) processes on April 16, 2003.

"You have to have a file or something out there to start sending to clearinghouses or [other health care entities]," she says. "We use a company called Nebo Systems Inc. [based in Oakbrook Terrace, IL] for on-line insurance verification and eligibility. It has a product called eCare that puts edits on the billing side. So we have to make sure [that company] is compliant."

Most of what had been holding up progress is that Medicare and most state Medicaid programs were not ready to proceed with EDI, Cappiello notes.

Liz Kehrer, CHAM, system administrator for patient access at Centegra Health System in McHenry, IL, has been focusing extensively on HIPAA compliance preparations.

One of the paths she followed during her research regarding transaction and code-set regulations began with the reference in a HIPAA guidebook to ISO (International Organization for Standardization), the Geneva-based organization that was cited as the source to use for the codes to be used in referring to various countries in electronic health care transmissions.

"Every business that interacts with the processing of the claim must follow a standard format," Kehrer notes. That ensures that all health care entities communicating about, say, the hospital care received by a person on vacation or someone studying abroad, are speaking the same language, she adds. "When submitting a claim, they all must refer to a country with the same identifier."

The most difficult thing about the HIPAA regulations, Kehrer points out, is that they don’t explain how to go about doing that. While communicating with her peers across the country on a listserv, she discovered that many were not aware of the HIPAA guide from Washington Publishing Co. that has been instrumental in her preparation: The National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim: Institutional is available at as either a bound document or an electronic document, she adds.

Using an Internet search engine, Kehrer found that the ISO country codes are kept current by the United Nations, which has a listing of codes and abbreviations on its web site. "We had to go into our computer system and update [the abbreviations] we had, so [communications are accurate] if we have a patient from a particular country who has insurance in that country."

The guide also addresses such issues as what information in the UB92 paper claim needs to be passed over to the electronic claim, she adds. "Another piece is the requirement for the weight of a newborn. Some [providers] may be using pounds, some grams, but remember that because we’re standardizing, the information needs to be on the claim in consistent format.

"We’re educating the staff in our obstetrics area that when a newborn is registered, the weight is part of that communication," she adds.

The hospital chain HCA recently announced plans to change its charitable care policies to provide financial relief to more of its charity patients and give needs-based discounts to uninsured patients who receive nonelective care at its hospitals. The planned changes, which are subject to approval by the Centers for Medicare & Medicaid Services, would allow patients who receive nonelective care at an HCA hospital and have income at or below 200% of the federal poverty level to be eligible for charity care, a standard it said about 70% of its hospitals already have been using.

HCA also has issued a revised policy on its criteria for filing liens or garnishment of wages of patients who have not paid their hospital bills. The policy prohibits placement of liens on primary homes worth less than $300,000 or garnishment of wages for patients who have a proven inability to pay.

(For information, go to the HCA web site at