Take a deep breath; then prepare for EDI deadline

Testing should already have begun

Just as hospitals take a breath after rushing to make sure they are in compliance with the privacy standard, it’s time to get in gear for the upcoming transaction code-set deadline mandated by the Health Insurance Portability and Accountability Act (HIPAA), 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 transmitted 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 Chicago’s Swedish Covenant Hospital, 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 into transaction and code-set regulations began with the reference in a HIPAA guidebook to ISO (International Organization for Standardization), the Geneva, Switzerland-based organization that was cited as the source 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.

It’s titled "National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim: Institutional," and is available through www.wpc-edi.com as either a bound document or an electronic document, Kehrer adds.

By using an Internet search engine, Kehrer adds, she ultimately 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," Kehrer says.

The guide also addresses such issues as what information in the UB-92 paper claim needs to be passed over to the electronic claim, she adds.

"Another piece is the requirement for the weight of a newborn," Kehrer points out. "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.