The Health Insurance Portability and Accountability Act (HIPAA) Transactions, Code Sets and Identifiers (TCS&I) Office facilitates the implementation of nationwide standards of HIPAA-compliant electronic administrative health care transactions for the Military Health System (MHS). The current adopted transaction standards are:
- X12 Insurance (X12N), Version 5010
- National Council for Prescription Drug Programs (NCPDP) Telecommunication, Version D.0
- NCPDP Medicaid Subrogation, Version 3.0
Health plans, clearinghouses, and providers are required to submit or receive these adopted electronic transactions for the purposes intended in order to be HIPAA compliant. The adopted transactions used by the MHS are listed in their business process sequence in the Transactions Table. Applicable transactions have been implemented successfully and are currently in use by the MHS.
The original Transactions and Code Sets Final Rule, dated August 2000, adopted American National Standards Institute (ANSI) X12 (Version 4010) and NCPDP Telecommunication Standard Version 5.1 and Batch Standard Version 1.0 transaction standards for eight types of administrative transactions.
In January 2009, the Department of Health and Human Services (HHS) published the Modifications to HIPAA Electronic Transaction Standards Final Rule which adopted updated versions (X12 Version 5010 and NCPDP D.0) of the standards that were adopted in 2000. The 2009 Final Rule also adopted standards to be used for Medicaid Pharmacy Subrogation and billing of retail pharmacy professional services and supplies. The compliance date for use of the updated versions was January 1, 2012.
Within the next two years, the industry is anticipating adoption of the next version of X12N and NCPDP Telecommunication transactions.
In addition to X12 and NCPDP, the HIPAA TCS&I Office has worked with and is currently monitoring several other transaction initiatives, including Electronic Funds Transfer (EFT) and Remittance Advice (RA), Operating Rules for HIPAA Transactions, Electronic Clinical Attachments, and Certification of HIPAA Compliance.
View questions and answers about the nationwide standards for HIPAA compliant electronic administrative health care transactions.
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The TRICARE Managed Care Support Contractors (MCSCs) have provided companion guides for some of the HIPAA transactions they perform. Please contact the MCSC point of contact for your region to obtain the latest information.
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The GIQD is a web-based, direct data entry system which allows authorized users to make eligibility inquiries. The GIQD has been updated to include HIPAA-compliant data elements and can be used in lieu of a direct Electronic Data Interchange (EDI) with DEERS.
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The DOES application is a web-based, direct data entry system which can be utilized by Managed Care Support Contractors (MCSCs) to enroll TRICARE beneficiaries into TRICARE programs in the Defense Enrollment Eligibility Reporting System (DEERS). DOES has been updated to include HIPAA-compliant data elements. The system includes upgraded security features and was deployed to all users as of May 2003. All TRICARE enrollments are performed using the HIPAA-compliant DOES application.
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The Centers for Medicare and Medicaid Services (CMS) published a Claims Attachments Notice of Proposed Rulemaking (NPRM) (CMS-005-0-F) in the Federal Register in September 2005. However, that NPRM was withdrawn in 2010 because of technology and business need changes. The Patient Protection and Affordable Care Act of 2010 (also known as ACA) requires the Department of Health and Human Services (HHS) to publish a Final Rule to adopt a Claims Attachment Standard and Operating Rules by January 2014 with an effective date not later than January 2016. Please note, while originally called "Claims Attachments" the health care industry has shifted toward the phrase "Clinical Attachments" to reflect the broader usage of the standard for purposes including but not limited to claims, referrals, and requests for pre-authorization. On 5 July 2016, National Committee on Vital and Health Services (NCVHS), the statutory advisory committee responsible for providing recommendations on health information policy and standards to HHS, recommended HHS publish a Final Rule to adopt a Clinical Attachment standard. As of January 2017, a Final Rule to adopt a Clinical Attachments Standard and Operating Rules had not been published.
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In a Final Rule published by the Department of Health and Human Services (HHS) in January 2009, covered entities were mandated to be in full compliance with Version 5010 and NCPDP Version D.0 by January 1, 2012. The Military Health System (MHS) successfully implemented the EDI standards and is in compliance with the Final Rule.
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