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The Health Care Finance Administration (HCFA) has issued a final rule under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) adopting standards for eight electronic transactions and code sets to be used in those transactions. It contains requirements concerning the use of these standards by health plans, health care clearinghouses and health care providers that transmit health care information in electronic form (“covered entities”). The rules specify that transactions involving the following types of information exchanges are subject to the electronic data interchange (EDI) standards:

• Health care claims or equivalent encounter information
• Eligibility for a health plan
• Referral certification and authorization
• Health care claim status
• Enrollment and disenrollment in a health plan
• Health care payment and remittance advice
• Health plan premium payments
• Coordination of benefits

For each transaction, the rule specifies format, data elements and data content.

Under the rule, covered entities that transmit information electronically will be required to use and accept the standard electronic codes for each of the transactions listed above. Specifications for these standards are contained in the HIPAA implementation guides adopted by the X12N Insurance Subcommittee.

The final rule became effective October 16, 2000 and full compliance will be required by October 16, 2002. Small health plans (less than $5,000,000 in annual gross receipts) will have until October 16, 2003 to comply. For further information regarding the HIPAA transactions and code sets final rule please contact Jeanette C. Schreiber at 203-498-4334 (e-mail address: [email protected]), Michelle Wilcox DeBarge at 860-297-3702 (e-mail address: [email protected]), or Paul Sean Curtin at 203-498-4359 (e-mail address: [email protected]).