Loyola Univ. Health Sys.

Transactions

Medicare announces plan to accept non-compliant electronic transactions after October 16, 2003

Memo to TSCS Project Team Members (pdf)
Initial TSCS Survey (pdf)
Outline of Audit Report (pdf)
Transactions Standard Regulation

Overview of the HIPAA Transaction Standards & Code Sets Regulation

The HIPAA Transaction Standards & Code Sets Regulation ("TSCS Regulation") was adopted on October 16, 2000. It established standards for the electronic exchange of administrative and financial health care transactions, which are needed to improve the efficiency and effectiveness of the health care system. Today, about 400 different formats exist for health care claims and encounters submitted electronically. Because of the national standards created under the TSCS Regulation, health care providers will be able to submit the same transaction to any health plan in the United States and the health plan must have the ability to accept it. Also, health plans will be able to send standard electronic transactions such as remittance advices and referral authorizations to health care providers.

The general rule regarding compliance is that if a covered entity (health care provider, health plan or healthcare clearing house) transmits a transaction defined in the TSCS Regulation electronically, the covered entity must conduct the transaction as a Standard Transaction. The TSCS Regulation provides an exception for direct data entry transactions (e.g. using dumb terminals or browsers) and use of a business associate (e.g., a health care provider using a health care clearinghouse). While health care providers may or may not choose to transmit electronically, health plans must provide the capability to do so at the request of the health care providers no later than October 16, 2002, unless a covered entity files a request for an extension by October 15, 2002.

Standard Transactions

The Standard Transactions defined in the TSCS Regulation include:

Health Care Claim or Encounter (837)

Enrollment and Disenrollment in a Health Plan (834)

Eligibility for a Health Plan (270-271)

Claim Payment and Remittance Advice (835)

Premium Payments (820)

Health Care Claim Status (276-277)

Referral Certification and Authorization (278).

Other Standard Transactions are identified in the TSCS Regulation but not finalized. They include:

Health Care Claim Attachment (275)

First Report of Injury (148).

Code Sets

The TSCS Regulation also identifies certain code sets that must be implemented in conjunction with the use of the Standard Transactions. A code set is defined as any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes.

Examples of the code sets captured in the TSCS Regulation are: ICD-9-CM, CPT-4, HCPCS, CDT, and NCD.

Standards

All of the standards adopted by the TSCS Regulation are from the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N except the standards for retail pharmacy transactions, which are from the National Council for Prescription Drug Programs (NCPDP).

The ANSI ASC X12 Standard is a uniform syntax for packaging ASCII data items along with a set of standard, predefined code-table values and cross-references. The syntax is a simple structure of labels, positional rules, and looping structure applied to the ordinary ASCII data. The data is packaged into Electronic Envelopes. Data is passed based upon those syntax rules and code values organized at four levels of detail. Data can be coded in X12 on one platform (computer) and transmitted via any means (tape, floppy diskette, telecommunication, etc.) to any other platform having an interpreter of X12.

The "Standard" is simply the coding format used. The Four Levels of Detail are:

The Transmission Control Standard – provides the overall electronic envelope in which one or more X12 packages are carried

The Transaction Set Standard – roughly equivalent to a generic type of business document. (eg: 835 Standard for Claim Payment/Advice)

The Segment Directory – each segment roughly equivalent to one financial transaction

The Data Element Dictionary – individual data elements that make up each segment.

The "Standard" is a very precise method of defining information to be transmitted in an electronic format. The data is formatted by the sender, then sent via any mechanical means, and then interpreted back by the receiver.

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Last Updated: September 29, 2003