HIPAA Electronic Transactions and Code Set (TCS) Rule
(45 CFR Parts 160, 162)

The HIPAA transactions standard applies to the following electronic transactions: health claim or encounter information; payment and remittance advice; claim status; enrollment/disenrollment in a plan; plan eligibility; health plan premium payments; referral certification/authorization; first report of injury; health claim attachments; and coordination of benefits (COB). HIPAA-recognized code sets include ICD-9M, CPT-4, and HCPCS; local codes are prohibited.

The final Transactions/Code Sets (TCS) standards were published on August 17, 2000. The compliance deadline (with exceptions) for covered entities that applied for extensions as authorized by Congress was October 16, 2003. For information on the HIPAA TCS standards, go to http://www.cms.hhs.gov/hipaa/hipaa2/default.asp.

CMS has issued notice that effective October 1, 2005, it will not process incoming electronic claims that fail to meet the requirements of HIPAA's TCS standards. Any non-HIPAA compliant electronic Medicare claim submitted for payment after that date will be returned to the filer for re-submission as a compliant claim. With this announcement, CMS terminated its contingency plan whereby it accepted non-HIPAA compliant claims under Medicare fee-for-service. Please note: Medicare's contingency plan for noncompliant submission of other HIPAA transactions remains in effect; the remittance advice transaction is the next HIPAA transaction for which CMS will end its contingency plan. For additional information, search the CMS Medlearn site, http://new.cms.hhs.gov/MedlearnNetworkGenInfo/

On November 21, 2005, CMS extended the comment period on its proposed rule (September 23, 2005 Federal Register) recommending industry-wide adoption of two X12N transaction standards to facilitate the electronic exchange of clinical and administrative data to further improve the claims attachment adjudication process when addition documentation is required. Comments now are due January 23, 2006. For additional information, go to http://www.cms.hhs.gov/hipaa/hipaa2/default.asp

On November 25, 2005, CMS issues a final rule clarifying those instances in which an electronic claim is not required in order to receive Medicare payment consistent with the requirements of the Administrative Simplification Compliance Act (ASCA). The ASCA, a federal law separate from but related to HIPAA, requires Medicare providers and suppliers to submit claims electronically to Medicare and those claims must be compliant with the HIPAA TCS rule. The final rule outlines exceptions for small providers as well as for direct submissions by Medicare beneficiaries lacking electronic access.