HIPAA: Humana Sets Contingency Plan

To assist physicians who are making a good-faith effort to meet the new Health Insurance Portability and Accountability Act (HIPAA) transaction and code-set standards but need a little more time, Humana has established a contingency plan. Humana will continue to accept and process claim transactions sent in pre-HIPAA electronic formats from providers who are in the process of implementing the needed systems or software.

The contingency plan will remain in force until all physicians and clearinghouses are capable of transmitting the fully compliant HIPAA standard transactions, said Bill Baldwin, Humana’s HIPAA project director. “We are committed to working with physicians and other care providers during this transition period, which we know has proved challenging for many physician offices. We appreciate that they continue to care for our members during this time, and we are committed to processing their electronic claims until they can achieve compliance.”

On another note, the newly enacted transaction and code set standards — as well as the HIPAA privacy regulations that went into effect last spring — continue to cause some confusion among physicians.

Following are answers to some commonly asked questions and links to online resources:

Q What are the different adjudication requirements — and doesn’t HIPAA mandate all electronic claims be standard?
A HIPAA requires that all electronic claims be submitted in a standard format and that they comply with all required data elements and those situational data elements that are applicable based on the conditions described in the HIPAA guide. HIPAA does not impact payers’ coverage rules. The Medicare free-billing software is being developed to support the submission of Medicare HIPAA compliant claims only and will not capture any of the situational data elements that may apply to other payers, but not to Medicare.

Q Are HIPAA-covered entities protected when they make patient-information disclosures to Quality Improvement Organizations (QIOs)?
A Under the Social Security Act, no person providing information to a QIO will be held responsible for violating a criminal law or be civilly liable under any state or federal law for providing requested information, unless that information is unrelated to the performance of the contract of the QIO — or the information is false and the person had reason to believe that the information was false.

Q Are “small providers” exempt from HIPAA?
A The term “small providers” first appeared in the Administrative Simplification Compliance Act (ASCA), the law requiring providers/submitters who bill Medicare to begin submitting HIPAA-formatted electronic claims to Medicare on October 16, 2003. ASCA does provide an exception to the Medicare electronic claims submission requirements to “small providers,” defining such providers as entities with fewer than 25 full-time equivalent employees or a physician, practitioner or facility with fewer than 10 full-time equivalent employees. However, the exemption applies to “small physicians” and other health care providers billing Medicare only; any provider who transmits claims data electronically, regardless of the number of employees, must use the HIPAA standard format.

For more information on HIPAA requirements and related claim-filing
and privacy issues, visit the Centers for Medicare and Medicaid Web site, http://www.cms.hhs.gov/hipaa/hipaa2/. In the Education Materials section of the site, physicians will find a wealth of valuable resources, including a “Provider Readiness” checklist, a HIPAA list-serve and a frequently updated FAQ section, among other offerings.

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