HIPAA Standard Transaction - Claims Status Inquiry and Response

An inquiry sent by a provider and the response from a health plan about the status of a claim or encounter submitted for processing.
1. ASC X12N 276-277
2. NCPDP for Retail Pharmacy Transactions

HIPAA Standard Transactions - Prior Authorizations and Referrals (278)

An enquiry sent by a provider to a health plan and the response regarding a patient's prior authorization or referral for services.
1. Uses ASC X12N 278
2. NCPDP for Retail Pharmacy Transactions

HIPAA Standard Transaction - Eligibility Inquiry and Response

Enquiry sent by a provider to a health plan and its response regarding a patient's eligibility for coverage or the benefits for which a patient may be eligible.
1. Uses ASC X12N 270-271
2. NCPDP for Retail Pharmacy transactions

HIPAA Standard Transaction - Remittance Advice

Explanation of claim or encounter processing and/or payment details sent by health plan to provider. Uses ASC X12N 835.

HIPAA Standard Transaction - Claims or Encounters

Covers health care service information (detailed, itemized record of services provided) submitted to health plans for reimbursement.
Can be of 4 kinds:
1. 837 Professional (doctors) (link)
2. 837 Institutional (hospitals)
3. 837 Dental
4. NCPDP Retail Pharmacy Transactions (link)

HIPAA In Brief

www.cms.hhs.gov

- Covers health plans, clearing houses and providers
- Specifies around 10 standard transactions for the transmission of health care information via Electronic Data Interchange. Covered entities should use these standards for transmission.
- Specifies codes and code sets to be used in these transactions such as:
1. Employer Identification Number (EIN) from IRS
2. National Provider Identifier, a 10-digit number
3. ICD-9 (ICD-10) codes for diagnoses
4. CPT, CDT and HCPCS for procedures and services
- Also regulations around security of private health information, etc
- The standard HIPAA transactions are:
1. Claims or Encounters
2. Payment and Remittance Advice
3. Claim status inquiry and response
4. Eligibility inquiry and response
5. Enrollment and Disenrollment
6. Premium payment
7. Coordination of Benefits
8. Referrals and Authorization enquiry and response
9. Claims attachments
10. First report of injury

It is important to note that HIPAA only mandates the use for the standard formats if health care data is being transmitted electronically; if a provider is using paper forms, then it is up to them and their health plans to see if they want to continue that way and for how long. If a health plan mandates electronic transfers and a provider wants to continue using paper forms, then a clearinghouse will have to be used in between who will do the conversion as part of their pre-adjudication process. Also, the formats are meant for computers and are not human-readable!

Also, HIPAA specifies standard codes to be used even for non-medical administrative information that is transmitted with claims like zip codes, area codes, state abbreviations and even for all the "drop-downs" in the forms like Provider Taxonomy codes (identifying provider's specialization), Remittance Advice Remarks codes, Payment Advice Adjustment codes, Claim Status codes, Claims status category codes, etc.

Shredding XML documents into tables

DB2 provides two ways of shredding XML documents into tables:
1. Using the XMLTABLE function. This is simpler and seems quite flexible in that it allows transformations and joins during the process too but the only downside is that each target table will need a separate INSERT statement. All the INSERTS can be bunched into an SP to make processing atomic and efficient.
2. Using Annotated Schema Decomposition. In this case, an XML schema is set up with annotations which map the XML elements to relevant table/columns and DB2 uses this info to do the shredding and inserting. Adv is that a single INSERT statement can write to multiple tables and also, the whole thing can be set up using the Data Studio GUI but the overall process can get quite complex.
A nice intro to the two options.