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HIPAA 5010 Transaction Update

Background

Over the past year, AmeriHealth has been diligently working towards updating compliance with the electronic transaction and code set standards adopted pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and revised by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) in January 2009.

AmeriHealth will be able to comply fully with the updated HIPAA transaction and code set regulations by January 1, 2012. However, in accordance with guidance published by CMS, AmeriHealth has developed a strategy to handle the receipt and processing of non-compliant electronic transactions received from health care providers and other covered entities (collectively referred to herein as “trading partners”) for a ninety (90) day period beginning January 1, 2012 to ensure the smooth flow of payments.

Demonstrating Compliance

• AmeriHealth will be production ready and able to transact (i.e., accept and transmit) the ASC X12 5010 version of all electronic health care transactions on January 1, 2012.
• AmeriHealth will have completed testing and connectivity of all electronic health care transactions (270/271, 276/277, 278, 820, 834, 835, 837) with all trading partners who become compliant with the electronic transaction and code set regulations.

Outreach

AmeriHealth, or AmeriHealth’s delegate (e.g., NaviNet^®), has made reasonable and diligent efforts to facilitate compliance with the electronic transaction and code set regulations by all trading partners by employing the following actions:

• Contacted each existing trading partner, provider and/or clearinghouse to remind them of the impending January 1, 2012 compliance date and AmeriHealth’s intent regarding their compliance.
• Conducted regular conference calls with each existing trading partner to monitor status of trading partner testing, address issues and make changes, as required.
• Maintained dates and documentation of all trading partner contacts and meetings held to promote outreach and transaction testing.

AmeriHealth has also made reasonable and diligent efforts to assist providers using trading partners/clearinghouse to become compliant by January 1, 2012 by employing the following actions:

• Made testing opportunities available to the trading partners/clearinghouses identified by AmeriHealth’s participating providers.
• Maintained dates and documentation of all contacts and meetings held with trading partners/clearinghouses identified by participating providers to promote outreach and transaction testing.

Testing

AmeriHealth or AmeriHealth’s delegate has contacted each existing trading partner to advise of our testing readiness and established external testing tasks and timeframes for trading partner testing. AmeriHealth has also made testing opportunities available to those trading partners/clearinghouses identified by participating providers.

Facilitate Compliance of Trading Partners

• AmeriHealth has provided and distributed as well as made available via the AmeriHealth website, companion guide documentation which describes AmeriHealth specific requirements for each electronic transaction in those instances where the Implementation Guides permit AmeriHealth to impose plan-specific requirements.
• AmeriHealth has provided a web accessible self-test facility for professional claim submission trading partners to submit transactions and receive responses regarding content and format compliance.
• AmeriHealth will be available for trading partner testing with clearinghouses and/or providers and those clearinghouses identified by providers in advance of January 1, 2012.
• AmeriHealth will continue to test with trading partners post-January 1, 2012 as these trading partners seek to become compliant with the electronic transaction and code set regulations.

Contingency Planning Process

In the event that all existing electronic trading partners have not converted to the compliant transactions prior to the January 1 deadline, AmeriHealth will employ contingencies for a ninety day period, starting January 1 in order to mitigate unintended adverse effects on (i) provider’s cash flow and business operations during trading partners’ transition to the standards and (ii) the availability and quality of patient care.

CMS guidance states that “it would not initiate enforcement action until March 31, 2012, with respect to any HIPAA covered entity that is not in compliance with the ASC X12 Version 5010 standards.” In keeping within the spirit of this delayed enforcement approach, AmeriHealth will continue to accept and process HIPAA 4010A compliant transactions through March 31, 2012.

NaviNet^® is a registered trademark of NaviNet, Inc.

An AmeriHealth company holds a minority ownership interest in NaviNet, Inc.