[ Wednesday, December 18, 2002 ]


From Phoenix Health System's HIPAAdvisory:

This week's HIPAAnote...
*** Covered Transactions: Look Carefully, Because It isn’t All About Claims ***
If you’re a payer or a clearinghouse, HIPAA is clear -- you’re a covered entity. If you’re a provider, however, the situation is less obvious. For a provider, to be a covered entity, you have to conduct one of the covered transactions. For many providers, including most hospitals, it’s easy -- if you bill electronically, you’re covered. For many small physicians’ offices, the situation is less clear. Examine this list of the covered transactions:

Health claims or similar encounter information
Health care payment & remittance advice
Coordination of Benefits
Health claim status
Enrollment & dis-enrollment in a health plan
Eligibility for a health plan
Health plan premium payments
Referral certification & authorization
So what’s the catch? Simple -- many small physicians’ offices still bill on paper, but conduct one of the other transactions. The biggest offender? Eligibility inquiries. Many state Medicaid programs support the use of credit-card style terminals for eligibility verification, and that’s a standard electronic transaction.

Even if you already know you’re covered, there are strategic implications. Using the credit-card style eligibility machines, consider what happens once not only Medicaid, but all payers can provide standard eligibility transactions. It means that all eligibilities can be checked at the time of service, reducing the number of uncollectible bills. To do that, you need either an eligibility function in your existing systems, or some new software or service. In the rush to get HIPAA-compliant claims working, don’t lose sight of the other transactions, their benefits, and ways to obtain them.

Jeff [12:31 PM]

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