HIPAA X12 standards are a specific subset of the X12 library of standards. Developed within X12N, the Insurance subcommittee of X12, the HIPAA standards provide a strict and unambiguous interpretation of the various HIPAA transactions named in the Final Rule. This interpretation is presented in a format called an Implementation Guide. HIPAA Implementation Guides, sometimes referred to as IGs, document a specific interpretation of the syntax and semantics of each transaction.
The HIPAA Implementation Guides satisfy several requirements:
Comply with HIPAA and its associated rules
Facilitate a smooth transition to the EDI environment by providing standardized data requirements and content for users of each HIPAA transaction
Allow the electronic exchange of information from computer to computer without human involvement
The following table lists the transaction standards as implemented through the appropriate Guide Addenda. Computer-based transmissions of the following transaction types must comply with the HIPAA standards.
Historically, health providers and plans have used many different electronic formats. HIPAA’s primary goal is to simplify the complex process of administration and payment of health care claims by implementing a single transaction standard and establishing the code sets used.
Under the enacted regulations, health plans will be able to reimburse providers, authorize services, certify referrals, and coordinate benefits using a standardized electronic format. Additionally, providers will be able to check eligibility for coverage, check claim status, request referrals and service authorizations, and receive electronic remittance to post receivables.
HIPAA applies to the following health care organizations:
Health plans
Health care providers, such as hospitals and physicians, that conduct health transactions electronically
Health care clearing houses that convert health care data between HIPAA-compliant and non-compliant formats
Entities that pay health care claims, as well as the providers and clearinghouses exchanging electronic payment information with each other, are affected by HIPAA requirements.
For more detailed information on HIPAA and the Administrative Simplification provision, see the following Web sites:
HIPAA
X12 Implementation Guides are available to download from the Washington Publishing Company Web site.