Here are answers to many of the common questions OHCA received on the Medicaid Provider HIPAA Compliance Survey. These are specific to the application of the HIPAA Standard Transactions and Code Sets in the Oklahoma Medicaid Management Information System and the new Fiscal Agent, Electronic Data Systems (EDS). (There are other issues that are addressed by HIPAA including Privacy and Security which are not part of these questions.) For authoritative information on the official rules and regulations on HIPAA, please visit the Department of Health and Human Services website at: http://aspe.os.dhhs.gov/admnsimp/index.htm. Q: We currently send claims to Unisys. Is this changing? A: Yes. Unisys has been the fiscal agent for Oklahoma Medicaid contracted to handle all Medicaid billing and payment since 1986. On a regular schedule, OHCA must open the bid process for fiscal agents and enter a new contract period. During the most recent bid process, Electronic Data Systems (EDS) was selected to be the new fiscal agent. For the past 18 months, EDS has been designing our new Medicaid Management Information System (MMIS). It is planned to be in place on January 1, 2003. After the new system is in place, you will no longer submit claims to or receive payments from Unisys for Medicaid payments. Q: Is HIPAA an OHCA or EDS mandate? A: No. The Health Insurance Portability & Accountability Act of 1996, Public Law 104-191, HIPAA, is a federal mandate. The federal Department of Health and Human Services wrote the rules for implementing the Administrative Simplification portion of the law. OHCA and EDS do not determine rules and requirements set out by the federal government. The change to a new fiscal agent and the requirement for HIPAA compliance are two separate issues. It is important that you understand OHCA and EDS did not invent HIPAA. It is a federal mandate with which OHCA and EDS must also comply. Because of the timing of the implementation of a new Medicaid Management Information System (MMIS), we are implementing the HIPAA transaction standard formats at the same time that we implement the new MMIS. Q: What should I be doing to become HIPAA compliant? A: The answer to this question depends on your business processes. At a minimum, if you currently send claims to Oklahoma Medicaid electronically, you should be contacting your billing service, clearinghouse, software vendor, or internal information systems department for more information. You may also contact your professional association or visit some of the websites mentioned elsewhere in this document. It is important that each organization determine how they must comply with HIPAA. Q: Where can I get more information on HIPAA? A: There are many websites and magazine articles about HIPAA. In the quarterly provider newsletter from OHCA, there have been articles each issue for the last four issues that specifically talk about HIPAA. You can also go to the DHHS website to find the actual HIPAA rules and regulations http://aspe.hhs.gov/admnsimp/. The rule on standards for
Page 2 electronic submissions can be found at http://aspe.hhs.gov/admnsimp/final/txfin00.htm. The HIPAA Implementation Guides that contain the format specifications may be downloaded from http://www.wpc-edi.com/hipaa/hipaa_40.asp. Q: I need more information and education about HIPAA compliance. Are you conducting training? A: Yes. OHCA has incorporated HIPAA information into the regularly scheduled provider training over the past 18 months. We will continue to do so. Your professional association may also be a source of training or information specific to your practice. Q: I only employ 6 staff members. Does HIPAA apply to me? A: There is not a simple answer to this question. HIPAA applies to every medical provider, large or small, if they file electronic claims. It is important for each provider (and other health care entity) to determine for his or her own practice how HIPAA applies. Q: The OHCA survey I received earlier this year asked about compliance by the October 16, 2002 deadline, but I have heard OHCA will not be compliant until January 1, 2003 and the federal deadline has been extended to October 2003. Can you discuss these dates in more detail? A: The original implementation deadline for the HIPAA transactions and code sets was October 2002. In December 2001, the federal government extended the deadline to October 2003 for those who file a compliance plan with DHHS prior to the October 2002 deadline. (More information on the completion of the compliance plan can be found at http://www.cms.gov/hipaa/hipaa2/ascaform.asp.) All HIPAA covered entities that file a compliance plan must be compliant by October 2003 on the transactions and codes sets. There is also a requirement that testing must begin by April 2003. OHCA will be compliant by January 2003, concurrent with the implementation of the new EDS system. It would be confusing, and costly, for both OHCA and our providers to launch a new system in January that requires the EDS proprietary format and then implement the HIPAA formats by October. Therefore, we are moving ahead with our implementation of the HIPAA standard transaction set formats on January 1, 2003. Q: I need more clarification on what will be required in expense, hardware and software to be HIPAA compliant. A: The expense, hardware and software needs are different for every provider, depending on how you submit claims. If you currently use a billing service or clearing house you need to seek guidance from them on what changes they expect you to make, if any. If you file your own claims electronically, see the claims questions below for more information. If you file on paper, you are not mandated to make any changes to comply with the HIPAA electronic transaction set formats.
Page 3 Q: If you submit paper claims only, what does an organization have to do, if anything, to be HIPAA compliant? What changes will apply to paper claim filing? A: If you file paper claims currently, you can continue that practice. You may see a few changes that impact paper submission in January as a result of implementation of the new system. However, that information will be communicated to you with information on the transition to the new system. There is discussion at a national level of future changes to the paper formats to more closely align them with the HIPAA electronic formats; however, there is no official information on those potential changes at this time. Q: I submit paper claims because I must attach documents such as a referral to a specialist. Can I switch to the electronic method? A: With the implementation of HIPAA, it is possible to submit an electronic claim and submit a separate paper attachment for that claim. When you file the electronic claim, you assign an attachment control number. The paper attachment is then sent with a cover page containing the attachment control number. This process will be explained in provider training and in provider billing instructions. Since this process still requires the submission of the paper attachment, OHCA does not anticipate that this business process will provide any particular benefit to providers. HIPAA is looking at a standard format for electronic attachments. Those rules and transaction guides are expected to be in a later release for HIPAA implementation. Q: I feel that filing paper claims is more efficient. Can each office decide on their own which method to use? A: At this time, OHCA has not mandated that claims be submitted electronically. After implementing the new system, you may choose to file paper claims, electronic claims, submit a claim on the secured web site, or utilize a billing service/clearinghouse. However, any electronic transaction/file sent to EDS must be in the HIPAA standard format. Q: Currently, nursing home claims can only be submitted on paper. Will this change with EDS or HIPAA implementation? A: With the implementation of the EDS system, nursing homes will begin using the UB92 paper format for submission of paper claims. This will also allow nursing home providers to submit electronic claims in the HIPAA 837 Institutional format. Nursing homes will also be able to submit claims via the secured website in the new system. Q: Is it acceptable to submit paper claims after 10-16-2002? Am I required to bill electronically? What options are there to billing electronically? A: At this time, OHCA has not mandated that claims be submitted electronically. We will continue to accept paper claims after the implementation of the new system. (Please look at the following question for information on electronic billing options.)
Page 4 Q: I do not currently file Medicaid electronically, but would like to. How do I do that? A: When the new system is launched in January 2003, you will have several choices for claims submission. We will still accept paper claims. You can use our secure website to file electronically. You can use a billing service or clearinghouse. You can use practice management or billing software. It is the provider s discretion to decide the appropriate mechanism for their submission of claims. Q: I currently submit my electronic claims using software provided by OHCA. Am I compliant? A: The free software, shareware, given out many years ago is not HIPAA compliant. You may contact the original developer to see if they plan to upgrade to a HIPAA format. The functionality previously provided by that shareware will be available through our secure website which will meet the HIPAA transaction set rules. Q: Are there companies that sell compliant software? How do I find out about them? Does Medicaid provide the software to bill electronically or do we purchase it ourselves, and from where? A: As a state agency, we cannot endorse a particular software package. You may want to contact your professional association or other providers in your same area of practice to see what software they recommend. OHCA does not purchase or provide software to bill electronically. We will be offering a secured website where a provider can submit a claim. However, the provider is responsible for the costs of the connection to the Internet. Q: I currently mail in computer diskettes/disks and would like to continue to do so. Is this possible under the new system? A: EDS will accept disks by mail, if the data are in the HIPAA transaction set format. Q: I currently file claims over the phone line. Can I continue to do that? A: If you have a modem and Windows 98 or higher, you may file HIPAA formatted claims over a dial-up mechanism. The newer technology that we will be using will require that you have an operating system that includes certain software (a web browser to be exact). Additionally, providers will be able to submit/download batch transaction sets via the secured website. Q: The HIPAA survey referred to testing and test dates. Do I need to sign up for a test date? A: All providers planning to submit electronic claims will be required to test the transactions before actually filing their first claim. We anticipate testing will begin in September. Watch for information in your Provider Update newsletter and future mailings.
Page 5 Q: Will I be able to check claim status and patient eligibility electronically? A: We will continue to work with various eligibility/claim status vendors as well as have the capability to accept a batch transaction for checking claim status and patient eligibility. Additionally, with our new secure website you will be able to check claim status and patient eligibility via direct data entry into the system. Q: Will any of this affect my direct deposit payments? If I file electronically, must I receive payments electronically? A: HIPAA and the new EDS system do not change the way direct deposits are made. Electronic funds are still issued from the State Treasurer s office to your bank, if you have signed up for Direct Deposit. The method used to file claims does not affect the way you receive your payment. Q: I currently use a billing service or clearing house, what do I need to do differently? Will our service update for us or will they be obsolete? A: You need to discuss HIPAA compliance and formatting with your billing service or clearing house. It is important that you communicate the OHCA timeline information to those companies. Each company has their own schedule for becoming compliant, and for testing. OHCA and EDS do not regulate these private companies. The contract is between you and the organization you engage for those services.