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HIPAA EDI Transactions

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (PL 104-191) require use of national standards for electronic data interchange for certain administrative and financial transactions. The standards require the use of the ANSI X12N 4010 Format for electronic transactions along with a variety of industry standard code sets. The deadline for compliance is 10/16/2003 for entities that have filed for an extension. Please Note: HIPAA Transaction Standards only apply to a covered transaction that is conducted electronically and does not regulate paper transactions. Covered electronic transactions and code sets include;

Covered Transactions:

• Submitting claims for payment and remittance
• Enrolling and disenrolling an individual in a health plan
• Paying health care premiums
• Checking eligibility for health care benefits and coverage
• Requesting authorization for services
• Responding to requests for additional information to support a claim
• Coordinating the processing of a claims across different insurance companies
• Notifying the provider about the payment of a claim.

Code Sets:

• International Classification of Diseases (ICD-9-CM), for reporting diagnosis and inpatient hospital procedures.
• Health Care Financing Administration Common Procedure Coding System (HCPCS) and the Current Procedure Terminology (CPT-IV).
• National Drug Codes (NDC) for drugs and biologics
• The American Dental Association's Codes
• Others
  

CHNCT EDI Transaction Services:
Community Health Network of Connecticut (CHNCT) will provide the following services for submission and retrieval of applicable provider transactions. CHNCT will also require providers submitting electronically to use fully compliant/certified transactions (ANSI X12N Transactions or properly translated to ANSI X12N using Translation/Clearinghouse Services.

Claims and Transactions (Submissions to Community Health Network):

Testing and Submission of Transactions:

Community Health Network of Connecticut will be compliant in terms of functional transaction processing capability for all applicable transactions and code sets by the extension compliance date of 10/16/2003 and as specified above. It is recommended that providers certify each of the transactions and conduct testing with the claims clearinghouse. Testing directly through to CHNCT will be provided only at a first come first serve basis and as resources allow. CHNCT views full compliance as, end to end provider to plan compliant processing as specified by the HIPAA Transaction Regulations and enforcement interpretations by the Centers for Medicare and Medicaid Services(CMS).

Transactions can be certified through EDIFECS and other certification organizations. HIPAA Implementation Guides can also be found by clicking here and at CHNCT’s Website at www.chnct.org. Companion Guides (as available) for each transaction can be found on CHNCT’s Website or thru the applicable vendor.

Below is a table explaining the applicable provider related transactions and contact information.

Contact Information:

CHNCT (Community Health Network)
290 Pratt Street
Meriden, CT 06033
Telephone: 203-949-4000
Contact: Cecelia Lewandowski
E-mail: HIPAAEDISubmission@chnct.org

WebMD Envoy
One Century Place
26 Century Blvd., Suite 601
Nashville, Tennessee 37214
Telephone: (615) 885-3700
http://www.webmdenvoy.com/pages/general/productrfi-type.html