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EDI Transactions FAQ

This collection of frequently asked questions (FAQ) was developed to answer provider questions about EDI transactions.

What is HIPAA and how does it apply to EDI transactions?

Does HIPAA apply to me?

How does the current 5010 version differ from the previous 4010 standards?

When did HIPAA version 5010 replace HIPAA version 4010? Did CMS announce a grace period for HIPAA 5010 compliance?

Does AmeriHealth support the standard HIPAA transactions?

Does AmeriHealth send Functional Acknowledgments to submitters?

What are the HIPAA standard external code sets?

Do you accept paper claims?

Were there changes to the paper claims (e.g., UB-04 claim form, CMS-1500 claim form) because of 5010?

Where can I find additional information about HIPAA?

Does AmeriHealth provide instructions for submitting standard transactions? Do these instructions include specifications for transactions that explain the specific components AmeriHealth will require from providers to process information?

Who should I contact to submit HIPAA-compliant electronic transactions? Who should I contact to schedule testing with AmeriHealth?

What is HIPAA and how does it apply to EDI transactions?
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is the federal regulation that requires health care providers, health care clearinghouses, and health plans to use X12 standards when electronically reporting and inquiring about certain health care transactions. If you electronically submit standard transactions, you must comply with the current HIPAA 5010 standards.

Does HIPAA apply to me?
HIPAA applies to you if you are a covered entity (health care provider, health care clearinghouse, or health plan) and you currently submit standard electronic transactions, or if you want to begin electronically reporting (or inquiring about) health care transactions.

How does the current 5010 version differ from the previous 4010 standards?
The new HIPAA 5010 version improves and modifies version 4010 and 4010A. The documentation that explains how to report your claims and inquiries is easier to understand in the new 5010 version, and it fully supports reporting of both the National Provider Identifiers and the new International Classification of Diseases codes. The 5010 version is also more streamlined because unused content from 4010A has been removed.

When did HIPAA version 5010 replace HIPAA version 4010? Did CMS announce a grace period for HIPAA 5010 compliance?
Version 4010 standards were implemented on October 16, 2003. The U.S. Department of Health and Human Services (HHS) issued a rule requiring covered entities to move to the next generation of HIPAA electronic transaction standards (5010) by January 1, 2012. AmeriHealth was in compliance with the updated HIPAA 5010 transaction and code set regulations by January 1, 2012. However, the Centers for Medicare & Medicaid Services (CMS) issued a statement announcing two 90-day periods of enforcement discretion for compliance with the 5010 transaction standards. The final enforcement delay period expired on June 30, 2012, and AmeriHealth now requires all covered entities to submit electronic transactions using the 5010 standards.

Does AmeriHealth support the standard HIPAA transactions?
AmeriHealth supports all of the transaction formats and associated code sets as mandated by HIPAA, with the exception of the Health Care Claim: Dental (837D). This includes:

Standard transaction number Transaction name Transaction version
837I Health Care Claim: Institutional 005010X223A2
837P Health Care Claim: Professional 005010X222A1
835 Health Care Claim Payment/Advice 005010X221A1
999 Implementation Acknowledgment For Health Care Insurance 005010X231A1
834 Benefit Enrollment and Maintenance 005010X220A1
U2771 Unsolicited 277 — Claim Acknowledgment Transaction 005010XIBC

1Non-standard HIPAA 277 claim status transaction, serving as the AmeriHealth proprietary functional acknowledgment for ANSI 837 claims transactions.

Does AmeriHealth send Functional Acknowledgments to submitters?
Yes. A TA1 or 999, which are applicable to all X12 transactions, will be sent and may be received. A U277, which is unique to AmeriHealth, will be sent and may be received for all health care claim transactions.

What are the HIPAA standard external code sets?
There are numerous coding systems that have been designated as standard or acceptable for use when using the HIPAA mandated transactions. The HIPAA regulations specify under what circumstances each type of coding is required. Some of these requiring external code sets include:

  • ICD-9-CM Volume 1 and 2: Diagnosis Coding*
  • ICD-9-CM Volume 3: Inpatient Hospital Service Coding*
  • CPT-4: Physician Services Coding
  • CDT-3: Dental Services Coding
  • NDC (National Drug Codes): Retail Pharmacy
  • HCPCS: Other Health Related Services Coding

*For more information on the upcoming transition to ICD-10, please visit our ICD-10 page.

Do you accept paper claims?
Nothing in HIPAA precludes the submission of paper claims. However, the spirit and intent of the legislation is to encourage electronic commerce in health care to reduce administrative costs. Electronic transactions are a very efficient way to file claims and make inquiries. AmeriHealth strongly encourages you to submit claims electronically.

Were there changes to the paper claims (e.g., UB-04 claim form, CMS-1500 claim form) because of 5010?
No. The most recent versions of the paper claims accommodate the relevant data reported in version 5010.

Where can I find additional information about HIPAA?
General information about the HIPAA Privacy rule:

U.S. Department of Health & Human Services

General HIPAA information: Centers for Medicare & Medicaid Services
How to file a complaint (must be filed in writing by mail, email, or fax): http://www.hhs.gov/ocr/privacy/hipaa/complaints

Region III — Philadelphia (Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia) Barbara Holland, Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
150 S. Independence Mall West
Suite 372, Public Ledger Building
Philadelphia, PA 19106-9111
Phone: 1-800-368-1019
Fax: 215-861-4431
TDD: 1-800-537-7697

Does AmeriHealth provide instructions for submitting standard transactions? Do these instructions include specifications for transactions that explain the specific components AmeriHealth will require from providers to process information?
Yes. Please visit our EDI Forms page for HIPAA companion guides. The companion guides identify specific technical requirements for all mandated transactions.

Who should I contact to submit HIPAA-compliant electronic transactions? Who should I contact to schedule testing with AmeriHealth?
If you wish to schedule testing with AmeriHealth or submit HIPAA-compliant transactions, please contact Highmark EDI Operations at 1-800-992-0246.