Transaction and Code Sets Standard/Rule (HIPAA)
Health Insurance Portability and Accountability Act (HIPAA) regulations are divided into four Standards or Rules: (1) Privacy. (2) Security. (3) Identifiers. and (4) Transactions and Code Sets (TCS). The TCS Standard/Rule was first released in August 2000 and updated in May 2002; it took effect on 16 October 2003 for all covered entities.
(Normally, small covered entities have one year more than their large colleagues. However, the Administrative Simplification Compliance Act (PL107-105) provided a one-year extension for large covered entities that submitted a compliance plan by 15 October 2002. Small entities were not provided with an extension opportunity. For other rule dates, see the HIPAA compliance calendar .)
Regulations associated with the TCS Rule mandate uniform electronic interchange formats for all covered entities. It is this standardization -- along with the introduction of uniform identifiers for plans, providers, employers and patients under the Identifier Rule -- that is expected to produce the lion's share of the efficiency savings of "administrative simplification ."
Unlike the HIPAA Privacy Rule. which applies to protected health information (PHI) in "any form or medium," the TCS Rule covers only PHI in electronic form. (Perhaps it is self-evident that an electronic format standard could apply only to electronically-rendered information. However, this "electronic focus" is true of the HIPAA Identifier and Security rules as well. For more information, see the discussion of electronic applicability under the Security Rule.)
While many entities in the health sector have developed, or are in the process of developing, electronic data interchange (EDI) standards, the consensus remains that "the lack
of common, industry-wide standards [is] a major obstacle to realizing potential efficiency and savings." (Final TCS Rule, p.3) Hence HIPAA allows the US Department of Health and Human Services (DHHS) to select the best of these efforts and require their use by all covered entities.
The TCS Rule has selected its standards from among the preexisting transaction and code set specifications of a variety of non-governmental designated standards maintenance organizations (DSMOs). The DSMOs retain the primary responsibility for updating their standards as evolving health sector needs dictate. (The Secretary of DHHS may at any time pick an alternative to those from DMSOs if it will substantially reduce administrative costs. But any new standard must be promulgated using formal rulemaking procedures, including appropriate time for notice and comment.)
At present, the TCS Rule encompasses the following standard electronic transaction formats -- preponderantly derived from the ANSI X12N standards.
- Health Care Claims or equivalent encounter information (X12N 837);
- Eligibility for a Health Plan (X12N 270/271);
- Referral Certification and Authorization (X12N 278 or NCPDP for retail pharmacy);
- Health Care Claim Status (X12N 276/277);
- Enrollment and Disenrollment in a Health Plan (X12N 834);
- Health Care Payment and Remittance Advice (X12N 835);
- Health Plan Premium Payments (X12N 820); and
- Coordination of Benefits (X12N 837 or NCPDP for retail pharmacy).
Copies of the detailed implementation specifications for each X12N standard may be downloaded for free. (Note, however, that each one runs several hundred pages.)
Within these transactions, the standards for coding information include:
Last modified: 11-May-2005 [RC]