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HIPAA Privacy/ Security/ Transaction Code Sets
 
HIPAA Privacy

Required to comply:

HIPAA has identified specific types of health care entities that must comply with the Privacy standards.  These HIPAA Covered Entities have been organized and classified under the following groups: “Health Care” includes mental health related care and treatment information

Health Care Providers:

  • Hospitals
  • Clinics
  • Doctor offices
  • Other health care providers 

Health Plans:

  • Health insurance companies
  • HMOs
  • Certain government programs (Medicare & Medicaid)
  • VA & Military Insurance Plans

Clearing Houses:

  • Medical billing company
  • Re-pricing company

Impact on individuals:

Privacy is important to all of us, especially when dealing with sensitive information such as our personal medical information. The HIPAA Privacy Standards establish rules that limit who can access medical records, defines the appropriate usages of health information, and identifies the manner in which health information must be handled and maintained. The Privacy Standards also grant individuals certain rights for managing their health information. Individuals may request access to their information and request corrections when necessary. They also have the right to know who has access to their health information and how it is being used. 

HIPAA Security

The HIPAA Security Standards establish administrative, technical and physical safeguards to protect the confidentiality, integrity and availability of the health information that HIPAA Covered Entities and Components create, receive, store, or disclosure remains secure and private.

HIPAA Transaction Code Sets (TCS)

The administration function of providing healthcare (i.e., patient enrollment, payment, benefit coordination, etc.) requires the exchange of certain medical information between healthcare entities. Much of this information exchange is done electronically. In an effort to standardize the information that is exchanged, HIPAA has established specific code sets called "Transaction Code Sets" that are authorized to be used for the 8 HIPAA approved transactions.
 

HIPAA Approved Transactions

HIPAA Approved Code Set

Health care claim and equivalent encounter

Retail drug 

NCPDP Telecommunication Standard Format version 5.1 and equivalent NCPDP Batch Standard Version 1.1

Dental claim 

ASC X12N 837 - Health Care Claim Dental
Version 004010X097A1

Professional claim

ASC X12N 837 - Health Care Claim Professional
Version 004010X098A1

Institutional claim 

ASC X12N 837 - Health Care Claim Institutional
Version 004010X096A1

Health care payment and remittance advice

 

ASC X12N 835 - Health Care Payment/Advice        Version 004010X091A1

Coordination of benefits

Retail drug 

NCPDP Telecommunication Standard Format version 5.1 and equivalent NCPDP Batch Standard Version 1.1

Dental claim 

ASC X12N 837 - Health Care Claim Dental
Version 004010X097A1

Professional claim 

ASC X12N 837 - Health Care Claim Professional
Version 004010X098A1

Institutional claim 

ASC X12N 837 - Health Care Claim Institutional
Version 004010X096A1

Health claim status

 

ASC X12N 276/277 - Health Care Claim Status Request and Response           Version 004010X093A1

Enrollment and disenrollment in a health plan

 

ASC X12 834 - Benefit Enrollment and Maintenance
Version 004010X095A1

Eligibility for a health plan

 

ASC X12N 270/271 - Health Care Eligibility Benefit Inquiry and Response           Version 004010X092A1

Health plan premium payments

 

ASC X12 820 - Payment Order/Remittance Advice
Version 004010X061A1

Referral certification and authorization

 

ASC X12N 278 - Health Care Services Review - Request for Review and Response  Version 004010X094A1

 

Disclaimer.
 
ADHS Web Privacy Policy
. This page last modified on May 30, 2008.
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