covered functions

Policy Memorandum 2004-53Exhibit

Health Insurance Portability

and Accountability

Act (HIPAA)

GLOSSARYTransactions and Code Sets

The tools and templates provided in CalOHI Policy and Information Memoranda have generally been authored by HIPAA workgroups. Users should view the information presented in the context of their own organizations and environments. Legal opinions and/or decision documentation may be needed when interpreting and/or applying this information.


TABLE OF CONTENTS

A........................................................................................................................................... 5Accredited Standards Committee (ASC) X12..................................................................5Administrative Code Sets.................................................................................................5American Dental Association (ADA).................................................................................5American Hospital Association (AHA)..............................................................................5American Medical Association (AMA)..............................................................................6American National Standards (ANS)................................................................................6American National Standards Institute (ANSI).................................................................6ASC X12N........................................................................................................................6Association for Electronic Health Care Transactions (AFEHCT)......................................7

B........................................................................................................................................... 7Benefit Enrollment / Disenrollment and Maintenance (834).............................................7

C........................................................................................................................................... 8Center for Medicare and Medicaid Services (CMS)-1500................................................8Claim Attachment.............................................................................................................8Claim Status Category Codes..........................................................................................9Claim Status Codes.........................................................................................................9Code Sets......................................................................................................................10Code Sets......................................................................................................................11Code Set Maintaining Organization................................................................................12Coordination of Benefits (COB)......................................................................................12Cross-Walk.....................................................................................................................12Current Dental Terminology (CDT)................................................................................12Current Procedural Terminology (CPT)..........................................................................13

D......................................................................................................................................... 13Data Condition...............................................................................................................13Data Content..................................................................................................................13Data Dictionary...............................................................................................................13Data Element.................................................................................................................14Data Interchange Standards Association.......................................................................14(DISA)............................................................................................................................14Data Mapping.................................................................................................................14Data Model.....................................................................................................................14Data Set.........................................................................................................................15Dental Content Committee.............................................................................................15Descriptor.......................................................................................................................15Designated Code Set.....................................................................................................15Designated Standards Maintenance Organization (DSMO)...........................................16Direct Data Entry............................................................................................................16

E..........................................................................................................................................17Electronic Data Interchange (EDI)..................................................................................17

Issued November 22 2004

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Electronic Healthcare Network Accreditation Commission (EHNAC).............................17The Electronic Healthcare Network Accreditation Commission.....................................17Electronic Media Claims (EMC).....................................................................................17

H......................................................................................................................................... 18Healthcare Common Procedure Coding System (HCPCS)...........................................18Healthcare Common Procedure Coding System (HCPCS) Level I................................18Healthcare Common Procedure Coding System (HCPCS) Level II...............................18Healthcare Common Procedure Coding System (HCPCS) Level III..............................19Healthcare Common Procedure Coding System (HCPCS) Procedure Modifier Codes.19Health Care Claim (837): Dental, Institutional, and Professional...................................19Health Care Claim Payment and Advice (835)...............................................................20Health Care Claim Status Request and Response (276/277)........................................20Health Care Code Maintenance Committee...................................................................21Health Care Eligibility Benefit Inquiry and Response (270/271).....................................21Health Care Financing Administration (HCFA) – 1500...................................................21Health Care Services Review (278) - Request for Review and Response.....................21Health Level Seven (HL7)..............................................................................................21

I...........................................................................................................................................22ICD.................................................................................................................................22ICD-9-CM.......................................................................................................................22ICD-10-CM.....................................................................................................................22Implementation Guide (IG).............................................................................................22International Organization for Standardization (ISO).....................................................23

L..........................................................................................................................................23Local Code(s).................................................................................................................23Logical Observation Identifiers, Names and Codes (LOINC).........................................23

M.........................................................................................................................................23Mapping.........................................................................................................................23Maximum Defined Data Set...........................................................................................24Medical Code Sets.........................................................................................................24Memorandum of Understanding (MOU).........................................................................24

N......................................................................................................................................... 24National Center for Health Statistics (NCHS).................................................................24National Council for Prescription Drug Programs (NCPDP)...........................................25National Drug Code (NDC)............................................................................................25National Standard Format (NSF)....................................................................................25National Uniform Billing Committee (NUBC)..................................................................25National Uniform Claim Committee (NUCC)..................................................................26Non-Medical Code Sets.................................................................................................26

P..........................................................................................................................................26Payroll Deducted and Other Group Premium Payment for Insurance Products (820)...26


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Pricer or Repricer...........................................................................................................26Provider Taxonomy Codes.............................................................................................27

S..........................................................................................................................................27Segment.........................................................................................................................27Standard Transaction.....................................................................................................27Strategic National Implementation Process (SNIP)........................................................27

T..........................................................................................................................................27Trading Partner..............................................................................................................27Transaction Change Request System............................................................................28Transactions and Code Sets (TCS) Rule.......................................................................29Translator.......................................................................................................................29

U......................................................................................................................................... 30UB-82.............................................................................................................................30UB-92.............................................................................................................................30Uniform Bill (UB)............................................................................................................30Uniform Claim Form (UCF)............................................................................................30

W.........................................................................................................................................30Washington Publishing Company (WPC).......................................................................30Workgroup for Electronic Data Interchange (WEDI)......................................................30

X..........................................................................................................................................30X12 Standard.................................................................................................................30XML................................................................................................................................30


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Term Definition

A(1)

Accredited Standards Committee (ASC) X12

The Accredited Standards Committee (ASC) X12 is an organization accredited and chartered by the American National Standards Institute (ANSI) to develop inter-industry electronic standards for a wide range of business applications.

For example, ASC X12 has been named a Designated Standards Maintenance Organization (DSMO) in the HIPAA Transactions and Code Sets (TCS) Rule.

[45 C.F.R. § 142.103]

For more information: www.x12.org

Administrative Code Sets

Administrative Code Sets are code sets that characterize a general business situation rather than a medical condition or service. Under HIPAA, these are sometimes referred to as non-clinical or non-medical code sets. For a comparison, see medical code sets.

For more information: Center for Medicare and Medicaid Services Glossary or www.cms.hhs.gov/glossary

American Dental Association (ADA)

The American Dental Association (ADA) is a professional organization for dentists responsible for maintenance of the hardcopy dental claim form, the associated submission specifications, and the Current Dental Terminology (CDT) code set. The ADA has a formal consultative role under HIPAA and hosts the Dental Content Committee.

For more information: www.ada.org/public/index.asp

American Hospital Association (AHA)

The American Hospital Association (AHA) is a health care industry association that represents the concerns of institutional providers. The AHA hosts the National Uniform Billing Committee (NUBC).

For more information: www.aha.org/aha/index.jsp

American Medical Association (AMA)

The American Medical Association (AMA) is a professional organization for physicians. The National Uniform Claim Committee (NUCC) is an AMA committee that has a formal consultative role under HIPAA. The AMA is responsible for the maintenance of the Current Procedural Terminology (CPT) code set.

For more information: www.ama-assn.org


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TWilliam, 01/03/-1,

http://www.ama-assn.org/

http://www.aha.org/aha/index.jsp

http://www.ada.org/public/index.asp

http://www.cms.hhs.gov/glossary

http://www.cms.hhs.gov/glossary/default.asp?Letter=ALL&Audience=7

http://www.x12.org/


Term Definition


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Term Definition

American National Standards (ANS)

The American National Standards (ANS) are guidelines for coordinating and developing consensus that include:

Clarification and consistency of language on a proposed standard,

Broad-based public review and comment, and

Incorporation of approved changes.

The American National Standards Institute (ANSI) facilitates the development and these standards.

For more information: www.ansi.org

American National Standards Institute (ANSI)

The American National Standards Institute (ANSI) is a private, non-profit organization that administers and coordinates the U.S. voluntary standardization and conformity assessment system. It promotes and facilitates voluntary consensus standards and conformity assessment systems. It facilitates the development of the American National Standards (ANS).

For more information: www.ansi.org

ASC X12N ASC X12N is the ASC X12 Subcommittee chartered to develop electronic standards specific to the insurance industry including healthcare.

[45 C.F.R. § 142.103]

For more information: www.x12.org

Association for Electronic Health Care Transactions (AFEHCT)

The Association for Electronic Health Care Transactions (AFEHCT) promotes efficient, secure, and cost-effective health information data exchanges in an open electronic environment utilizing industry standards for the health care vendor community. AFEHCT communicates usable and timely information about opportunities and obstacles in relevant federal and state health care policy formulation to the health care vendor community and others who share the association’s goals and interests. Through informed advocacy, the association influences legislative and regulatory policy-making that may impact health care Information Technology solutions associated with the delivery, financing, and administration of health care.

For more information: www.afehct.org


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http://www.afehct.org/

http://www.x12.org/

http://www.ansi.org/



Term Definition

B

Benefit Enrollment / Disenrollment and Maintenance (834)

The Benefit Enrollment/Disenrollment and Maintenance (834) is an X12 standard format for enrollment data. This transaction is used to transfer enrollment information from the sponsor of the insurance coverage, benefits, or policy to a payer (e.g. health plan).

For more information on the 834 see the ASC X12N Insurance Subcommittee Implementation Guides at: www.wpc-edi.com/Default_40.asp

Claim Adjustment Reason Codes

Claim Adjustment Reason Codes is a national standard administrative code set that identifies reasons for differences or adjustments between the original provider charge for a claim or service and the payer’s payment for it. This code set is used for ASC X12N Health Care Claim Payment and Advice (835) and ASC X12N Health Care Claim (837) formats, and is maintained by the Health Care Code Maintenance Committee.

For more information: www.wpc-edi.com.

C

Center for Medicare and Medicaid Services (CMS)-1500

The Center for Medicare and Medicaid Services (CMS)-1500 is the Centers for Medicare and Medicaid Services’ hardcopy claim form. This form may also be known as the Health Care Financing Administration (HCFA)-1500.

For more information: Center for Medicare and Medicaid Services Medicare Paper Claim Forms and Instructions, http://www.cms.hhs.gov/providers/edi/edi5.asp#Form%20CMS-1500 or www.cms.hhs.gov/glossary

Claim Attachment

A Claim Attachment can be one of a variety of hardcopy forms or electronic records used to provide supplemental information to electronic records for approval/payment of a claim itself.



8




http://www.cms.hhs.gov/providers/edi/edi5.asp#Form%20CMS-1500


http://www.wpc-edi.com/

http://www.wpc-edi.com/Default_40.asp



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Term Definition

Claim Status Category Codes

Claim Status Category Codes are a national administrative code set that indicate the general status of health care claims when they are accepted, rejected or additional information is needed. The Health Care Code Maintenance Committee is responsible for the maintenance of these codes.

For more information: www.wpc-edi.com

Claim Status Codes

Claim Status Codes are a standard national administrative code set used to provide details about claim being received, pended or paid. The Health Care Code Maintenance Committee is responsible for the maintenance of these codes.

For more information: www.wpc-edi.com

Code Sets Under HIPAA, code sets are sets of codes used to encode data elements, such as terms, medical concepts, medical diagnostic codes, or medical procedures. A code set consists of the codes and descriptors.

The Administrative Simplification (A/S) provisions of HIPAA require the Secretary of the U.S. Department of Health and Human Services (HHS) to adopt standard code sets for administrative and financial transactions.

The codes specified in the Transactions and Code Sets Rule and their applications are: International Classification of Diseases, 9th Edition, Clinical

Modification (ICD-9-CM), Volumes 1 and 2, Diagnosis(1) Diseases,(2) Injuries,(3) Impairments,(4) Other health problems and their manifestations, and(5) Causes of injury, disease, impairment, or other health problems.

International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM), Volume 3, Procedures(1) Prevention,(2) Diagnosis,(3) Treatment, and(4) Management.


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Term Definition

Code Sets(continued)

National Drug Codes (NDC) or Health Care Common Procedure Coding System (HCPCS)

(1) Prevention, and(2) Diagnosis.

Code on Dental Procedures and Nomenclature (CDT)(1) Prevention.

Combination of Healthcare Common Procedure Coding System (HCPCS – Level II) and Current Procedural Terminology, Fourth Edition (CPT – 4)

(1) Physician services,(2) Physical and occupational therapy services,(3) Radiologic procedures,(4) Clinical laboratory tests,(5) Other medical diagnostic procedures,(6) Hearing and vision services, and(7) Transportation services including ambulance.

Healthcare Common Procedure Coding System (HCPCS – Level II)

(1) Medical supplies,(2) Orthotic and prosthetic devices, and(3) Durable medical equipment.

[45 C.F.R. §§ 162.103 & 162.1002]


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Code Set Maintaining Organization

A Code Set Maintaining Organization is an organization under HIPAA that creates and maintains the code sets adopted by the Secretary of the U.S. Department of Health and Human Services (HHS) for use in transactions for which HIPAA standards are adopted. They are:

American Medical Association (AMA) , American Dental Association (ADA) , National Center for Health Statistics (NCHS) , Centers for Medicare and Medicaid Services (CMS), HCPCS National Editorial Panel, and Food and Drug Administration.

[45 C.F.R. § 162.103 ]

Coordination of Benefits (COB)

Coordination of Benefits (COB) is a process for determining the financial responsibilities of two or more health plans with financial responsibility for a medical claim (i.e. pharmacy, dental, professional and institutional claims).

[Federal Register, Vol. 65, No. 160, Thursday, August 17, 2000, pages 50335 - 50336]

Cross-Walk Cross-Walk is the conversion of a non-standard code set to the best corresponding code set of the National Code Sets (e.g. HCPCS, CPT, etc).

For converting transactions, see Data Mapping.

[45 C.F.R. Part 162. (Exhibit 1a)]

Current Dental Terminology (CDT)

Current Dental Terminology (CDT) is a dental procedure code set used in reporting dental services. These codes are included in the Health Care Common Procedure Coding System (HCPCS), maintained by the American Dental Association (ADA) and selected for use in HIPAA transactions.

For more Information: www.ADA.org

Current Procedural Terminology (CPT)

Current Procedural Terminology (CPT) is a medical code set of physician and other services, maintained and copyrighted by the American Medical Association (AMA), and adopted by U. S. Department of Health and Human Services (HHS) as the standard for reporting physician and other services on standard transactions.


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http://www.ADA.org/


For more information: www.ama-assn.org/ama/pub/category/3113.html


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http://www.ama-assn.org/ama/pub/category/3113.html


D Data Condition Data Condition is a guideline that describes the circumstances under which a covered entity must use a particular data element or segment.

For example: A physician (the billing provider) has seen a patient, but the payment for the physician’s services must go to the clinic for which the physician works part time. In this situation, a Health Care Claim (837) Professional would require a “pay to provider name” segment when the payment is made to the clinic, which is a provider that is different than the billing provider (per ASC X12N Insurance Subcommittee Implementation Guide). In this case, the requirement for a “pay to provider name” is a data condition.

[45 C.F.R. § 162.103 definition]

Data Content Data Content are all data elements and code sets inherent in a transaction not related to the format of the transaction. There are two types of data content:

1. Standardization of data elements, including their formats and definition. For example: a data element may define a field’s maximum size to be eight characters, or that the field is required or situational.

2. Standardization of the code sets or values that may appear in selected data elements. For example: a code set could be zip codes or procedure codes.

[45 C.F.R. § 162.103]

Data Dictionary A Data Dictionary is a document or system that lists the data, and their definitions, of a system.


Data Element A Data Element is the smallest named unit of information in a transaction under HIPAA. Data elements are identified as either simple or compound. Each data element has a name, description, type, minimum, and maximum length.

For example: Submitter Last Name or Organization Name is a data element that requires a maximum of 35 characters and a minimum of one character.


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[45 C.F.R. § 162.103]

Data Interchange Standards Association(DISA)

The Data Interchange Standards Association (DISA) is an organization that provides administrative services to ASC X12 and several other standards-related groups.

Examples of administrative services the DISA provides are:Specification Development:

Manage the specification setting process, Publish approved specifications, and Provide technical guidance.

Organization Administration: Provide corporate and general administration, Manage finances and accounting procedures, Offer membership recruitment, accounting, and retention

services, and Provide communications, marketing, and meeting support.

For more information: www.disa.org

Data Mapping Data Mapping is the process of matching one data element to its closest equivalent data element within a transaction. The term “Data Mapping” is interchangeable with the term “Cross-Walk”.

For converting local codes look up cross-walk.

Data Model A Data Model is a conceptual model of the information needed to support a business function or process.


Data Set A Data Set is meaningful unit of information exchanged between two parties in a transaction.

For example: A data set is similar to a computer file that contains information that can be processed by software programs. A data set is a computer file of raw claims, as well as, a computer file of approved claims.

[45 C.F.R. § 162.103]


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http://www.disa.org/


Dental Content Committee

Dental Content Committee is the organization hosted by the American Dental Association (ADA) responsible for the maintenance of the data element specifications for dental billing. The ADA has a formal consultative role under HIPAA for all transactions affecting dental health care services.

The Dental Content Committee of the ADA was named a Designated Standards Maintenance Organization (DSMO) in the HIPAA Transactions and Code Sets (TCS) Rule.

For more information: www.ada.org/goto/decc/index.html

Descriptor Descriptor is the text defining a code in a code set.

[45 C.F.R. § 162.103]

Designated Code Set

Designated Code Set is a medical code set or an administrative code set the U.S. Department of Health and Human Services (HHS) has designated for use in one or more of the HIPAA standards.

For more information check CMS Glossary: www.cms.hhs.gov/glossary


16


http://www.ada.org/goto/decc/index.html


Designated Standards Maintenance Organization (DSMO)

Designated Standards Maintenance Organization (DSMO) is the term used in the Transactions and Code Sets (TCS) Rule to identify the organizations designated by the Secretary of the U.S. Department of Health and Human Services (HHS) to:

Be responsible for maintenance of the standards for health care.

Receive and process requests to adopt new standards or modify adopted standards.

All six organizations named in the TCS Rule as DSMOs signed a Memorandum of Understanding (MOU) agreeing to undertake the functions specified in the TCS regulations and to follow a framework of cooperation with each other and HHS. These named organizations are:

Accredited Standards Committee , Health Level Seven (HL7) , National Council for Prescription Drug Programs (NCPDP) , National Uniform Billing Committee (NUBC) , National Uniform Claim Committee (NUCC) , and Dental Content Committee of the American Dental

Association (ADA) .

[45 C.F.R. §§ 162.103 & 162.910]

For more information: www.hipaa-dsmo.org/

Direct Data Entry

Direct Data Entry is the process of entering data into a database through a display monitor that has no processing capabilities. The data is then transmitted electronically to a health plan’s computer.

[45 C.F.R. § 162.103]


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http://tm.wc.ask.com/r?t=c&s=a3&id=30780&sv=za5cb0d76&uid=010164F43C1642304&sid=175EA864FA6F6EA04&p=%2Flinks&o=0&u=http://www.hipaa-dsmo.org/


Term Definition

E

Electronic Data Interchange (EDI)

Electronic Data Interchange (EDI) is the electronic transfer of information, such as electronic media health claims, in a standard format between trading partners. EDI allows entities within the health care system to exchange medical, billing, and other information and to process transactions. EDI is sometimes used more broadly to mean any electronic change of formatted data.

For more information: www.wedi.org

Electronic Healthcare Network Accreditation Commission (EHNAC)

The Electronic Healthcare Network Accreditation Commission (EHNAC) is a private organization that tests transactions for consistency with HIPAA requirements and accredits health care clearinghouses. EHNAC accredits entities engaged in e-health activities (electronic health care transactions and management of health care information) based on their ability to meet high quality performance standards in the areas of privacy, security, technical performance, and business practice. Covered entities may choose to perform EHNAC’s self-assessment and site review processes which assists in meeting industry-defined performance standards, which include, but are not limited to, Administrative Simplification (A/S) provisions of HIPAA. EHNAC accreditation informs health care industry organizations that entities engaged in e-health activities with which they may contract have been found HIPAA compliant by EHNAC.

For more information: www.ehnac.org

Electronic Media Claims (EMC)

Electronic Media Claims (EMC) is an electronic format used to transmit or transport claims.

For more information: www.cms.hhs.gov


18

Kris Young, 01/03/-1,

http://www.cms.hhs.gov/

http://www.ehnac.org/

http://www.wedi.org/


Term Definition

H Healthcare Common Procedure Coding System (HCPCS)

The Healthcare Common Procedure Coding System (HCPCS) is a medical code set for all substances, equipment, supplies or other items used in health care services except drugs and biologics. The items include, but are not limited to, the following:

1. Medical supplies,2. Orthotic and prosthetic devices, and3. Durable medical equipment.

HCPCS may also identify health care procedures, equipment and supplies. It has been selected for use in HIPAA transactions. HCPCS has three levels (Healthcare Common Procedure Coding System (HCPCS) Level 1, Healthcare Common Procedure Coding System (HCPCS) Level II and Healthcare Common Procedure Coding System (HCPCS) Level III with Healthcare Common Procedure Coding System (HCPCS) Procedure Modifier Codes).

[45 C.F.R. § 162.103 definition of HCPCS]

For more information: www.cms.hhs.gov/medicare/hcpcs

Healthcare Common Procedure Coding System (HCPCS) Level I

HCPCS Level I contains numeric Current Procedural Terminology (CPT) codes, which are maintained by the American Medical Association (AMA).


Healthcare Common Procedure Coding System (HCPCS) Level II

HCPCS Level II contains codes used to identify various items and services not included in the Current Procedural Terminology (CPT) medical code set, such as medical supplies, orthotic and prosthetic devices and durable medical equipment. The Centers for Medicare and Medicaid Services (CMS), Blue Cross and Blue Shield of America (BCBSA), and the Health Insurance Association of America (HIAA) maintain these codes.


Healthcare Common Procedure Coding System (HCPCS) Level III

HCPCS Level III contains codes assigned by Medicaid state agencies to identify additional items and services not included in HCPCS Levels I or II. These are usually called “local codes” and must have “W,” “X,” “Y,” or “Z” in the first position. HIPAA does not allow use of these codes.



19

http://www.cms.hhs.gov/medicare/hcpcs





Term Definition

Healthcare Common Procedure Coding System (HCPCS) Procedure Modifier Codes

HCPCS Procedure Modifier Codes, which is part of Level II, may be used to identify circumstances that alter or enhance the description of a service or supply.


Health Care Claim (837): Dental, Institutional, and Professional

The Health Care Claim (837) has three standard formats:

Dental is primarily for use by dentists for claims and/or encounters.

Institutional is primarily used by hospitals or clinics for claims and/or encounters, i.e., the UB-92 form.

Professional is primarily for use by physicians for claims and/or encounters, i.e., the CMS 1500 form.

For more information see ASC X12N Insurance Subcommittee Implementation Guide: www.wpc-edi.com/Default_40.asp

Health Care Claim Payment and Advice (835)

The Health Care Claim Payment and Advice (835) is a standard format for payment and advice. Payers send 835s to providers.

Health care providers receiving 835s include, but are not limited to, hospitals, nursing homes, laboratories, physicians, dentists, and allied professional groups.

Organizations sending 835s include insurance companies, Third Party Administrators (TPAs), service corporations, state and federal agencies and their contractors, health plan purchasers, and any other entities that process health care reimbursements.

Business partners affiliated with 835s include Depository Financial Institutions (DFIs), billing services, consulting services, vendors of systems, software and Electronic Data Interchange (EDI) translators, EDI network intermediaries, such as Automated Clearing Houses (ACHs), Value-Added Networks (VANs) and telecommunication services.



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Term Definition

Health Care Claim Status Request and Response (276/277)

The Health Care Claim Status Request and Response (276/277) are used for checking the status of health care claims. The 276 is the standard format used by health care providers or health plans to request the status of claims. The 277 is the standard format used by the responding entity to transmit the answers to the requests about the status of claims.

Entities requesting claim status information include but are not limited to: hospitals, nursing homes, laboratories, physicians, dentists, allied professional groups, employers, and supplemental (i.e., other than primary payer) health care claims adjudication processors.

Organizations responding to claim status requests include: payers who may be insurance companies, third party administrators, service corporations, state and federal agencies and their contractors, health plan purchasers, and any other entities that process health care reimbursements.


Health Care Code Maintenance Committee

The Health Care Code Maintenance Committee is an organization administered by the Blue Cross and Blue Shield of America (BCBSA) responsible for maintaining the Claim Adjustment Reason Codes, the Claim Status Category Codes, and the Claim Status Codes used in the X12 standard transactions and elsewhere.

For members of this committee:www.wpc-edi.com/AdjustmentStatusCodes/contacts.html

Health Care Eligibility Benefit Inquiry and Response (270/271)

The Health Care Eligibility Benefit Inquiry (270) and Response (271) are two standard formats: for requesting information and responding with answers on coverage, eligibility, and benefits.


Health Care Financing Administration (HCFA) – 1500

See Center for Medicare and Medicaid Services-1500.

For more information: Center for Medicare and Medicaid Services Medicare Paper Claim Forms and Instructions, http://www.cms.hhs.gov/providers/edi/edi5.asp#Form%20CMS-1500 or www.cms.hhs.gov/glossary


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http://www.wpc-edi.com/AdjustmentStatusCodes/contacts.html



Term Definition

Health Care Services Review (278) - Request for Review and Response

The Health Care Services Review (278) - Request for Review and Response is a standard format for review of specialty care, treatment, and admission (i.e. prior authorization).


Health Level Seven (HL7)

Health Level Seven (HL7) is one of several American National Standards Institute (ANSI) -accredited Standards Developing Organizations (SDOs) operating in the health care arena. Most SDOs produce standards (sometimes called specifications or protocols) for a particular health care domain such as pharmacy, medical devices, imaging or insurance (claims processing) transactions. The HL7 domain is clinical and administrative data. HL7 develops specifications; the most widely used being a messaging standard that enables disparate health care applications to exchange key sets of clinical and administrative data.

For more information: www.hl7.org

I ICD The International Classification of Diseases (ICD) is a medical code set maintained by the World Health Organization (WHO). The primary purpose of these codes is to classify causes of death. A U.S. extension of this coding system, maintained by the National Committee on Vital and Health Statistics (NCVHS) within the Centers for Disease Control (CDC), is used to identify morbidity factors, or diagnoses. (There are other ICDs; see ICD-9-CM or ICD-10-CM).

For more information: N C H S - Classification of Diseases , Functioning, and Disability.

ICD-9-CM The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is used in assigning codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the U.S. In addition, it is used in assigning codes associated with inpatient procedures. The ICD-9-CM is based on the ICD but provides for additional morbidity detail and is annually updated. This medical code set is published and maintained by National Center for Health Statistics (NCHS) for United States usage.

For more information: www.cdc.gov/nchs


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http://www.cdc.gov/nchs

http://www.cdc.gov/nchs/icd9.htm

http://www.cdc.gov/nchs/icd9.htm

http://www.hl7.org/





Term Definition

ICD-10-CM The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), is currently under development as a replacement to the ICD-9-CM code set and is not yet used in the United Sates. The ICD-10-CM was developed by the World Health Organization (WHO). The U.S. is preparing a clinical modification of ICD-10 to meet our expanded needs for morbidity data.

For more information: www.ncvhs.hhs.gov

Implementation Guide (IG)

The Implementation Guide (IG) is a document issued by the ASC X12N Insurance Subcommittee explaining the proper use of a standard for a specific business purpose.

For example: The ASC X12N HIPAA IGs are the primary reference documents used by those implementing the associated transactions, and are part of the HIPAA regulations by reference.

For more information on the Implementation Guides: www.wpc-edi.com/Default_40.asp

International Organization for Standardization (ISO)

The International Organization for Standardization (ISO) is a network of international standards institutes from 148 countries working in partnership with international organizations, governments, industry, and business and consumer representatives. The ISO serves as a bridge between the public and private sectors.

For more information: www.iso.org/iso/en/ISOOnline.openerpage

L Local Code(s) Local Codes are proprietary codes used by a state or other political subdivision, or by a payer to identify a specific product. This term is most commonly used to describe Healthcare Common Procedure Coding System (HCPCS) Level III Codes, but also applies to state-assigned Institutional Review Codes, Condition Codes, Occurrence Codes, Value Codes, etc. HIPAA does not allow use of these codes.

For more information: Center for Medicare and Medicaid Services Glossary or www.cms.hhs.gov/glossary.


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http://www.iso.org/iso/en/ISOOnline.openerpage



http://www.ncvhs.hhs.gov/


Term Definition

Logical Observation Identifiers, Names and Codes (LOINC)

Logical Observation Identifiers, Names and Codes (LOINC) are a set of universal names and identifier codes that identify lab and clinical observations. LOINC codes are maintained by the Regenstrief Institute (U.S.) and are expected to be used in the HIPAA claims attachments standard.

For more information: www.loinc.org or www.regenstrief.org/loinc/loinc.htm (for LOINC codes)

M

Mapping See Data Mapping.

Maximum Defined Data Set

A Maximum Defined Data Set is all of the required data element s for a particular standard based on a specific implementation specification. An entity creating a transaction may include whatever data are appropriate for the transaction. The recipient may ignore any portion of the data not needed to conduct their part of the associated business transaction, unless the inessential data is needed for Coordination of Benefits (COB).

For example: The zip code implementation specification limits the data elements to 15 characters for the maximum defined data set. A provider can submit the nine-digit zip code. The recipient accepting this claim may only choose the five digits for the zip code or none at all.

[45 C.F.R. § 162.103]

Medical Code Sets

Medical Code Sets are codes that characterize a medical condition or treatment. These code sets are usually maintained by professional societies and public health organizations.


Memorandum of Understanding (MOU)

A Memorandum of Understanding (MOU) is a document providing a general description of the responsibilities to be assumed by two or more parties in their pursuit of an identified goal(s).


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http://www.regenstrief.org/loinc/loinc.htm

http://www.loinc.org/


Term Definition

N National Center for Health Statistics (NCHS)

The National Center for Health Statistics (NCHS) is a public resource for health information. They compile statistical information for researchers and public use, to enhance policy analysis and discussion.

For more information: www.cdc.gov/nchs

National Council for Prescription Drug Programs (NCPDP)

The National Council for Prescription Drug Programs (NCPDP) is an ANSI-accredited group that maintains a number of standard formats for use by the retail pharmacy industry, some of which are included in the HIPAA mandates. The NCPDP was named as a Designated Standards Maintenance Organization (DSMO) in the Transactions and Code Sets (TCS) Rule.

For more information: www.ncpdp.org/

National Drug Code (NDC)

The National Drug Code (NDC) is a medical code set that identifies prescription drugs and some over the counter products, and has been selected for use in the HIPAA transactions.

For more information: www.fda.gov/cder/ndc

National Standard Format (NSF)

A National Standard Format (NSF) is any nationally standardized data format. Most often, this term is used to designate the Professional Electronic Media Claims (EMC) NSF, a flat file database used to submit claims.

For more information: www.cms.hhs.gov

National Uniform Billing Committee (NUBC)

The National Uniform Billing Committee (NUBC) is an organization chaired and hosted by the American Hospital Association (AHA) and responsible for the maintenance of institutional claims and formats. The NUBC has a formal consultative role under HIPAA for all transactions affecting institutional health care services and has been named as a Designated Standards Maintenance Organization (DSMO) in the Transactions and Code Sets (TCS) Rule.

For more information: www.nubc.org

National Uniform Claim Committee

The National Uniform Claim Committee (NUCC) is an organization chaired and hosted by the American Medical Association (AMA), and


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http://www.nubc.org/

http://www.cms.hhs.gov/

http://www.fda.gov/cder/ndc

http://tm.wc.ask.com/r?t=c&s=a1&id=30780&sv=za5cb0dc3&uid=0D5389905F4052B04&sid=1B58823A2CCF98C04&p=%2Flinks&o=0&u=http://www.ncpdp.org/

http://www.cdc.gov/nchs


Term Definition

(NUCC) is responsible for the maintenance of the professional Center for Medicare and Medicaid Services’ CMS-1500 uniform claim form , the professional Electronic Media Claims (EMC) National Standard Format (NSF) and the X12 standard Health Care Claim (837). The NUCC maintains the Provider Taxonomy Codes and has a formal consultative role under HIPAA for all transactions affecting non-dental and non-institutional professional health care services such as physician, nurses, etc. The NUCC is named as a Designated Standards Maintenance Organization (DSMO) in the Transactions and Code Sets (TCS) Rule.

For more information: www.nucc.org/links/index.html


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http://tm.wc.ask.com/r?t=c&s=a3&id=30780&sv=za5cb0db6&uid=010164F43C1642304&sid=175EA864FA6F6EA04&p=%2Flinks&o=0&u=http://www.nucc.org/links/index.html


Term Definition

Non-Medical Code Sets

The Non-Medical Code Sets are the standardized code sets in the transaction, such as:

Tables of terms, Types of provider, Type of services, Claim status, Adjustment reason, Race/ethnicity, Gender, and Zip code, etc.

[45 C.F.R. § 162.1000]

P

Payroll Deducted and Other Group Premium Payment for Insurance Products (820)

The Payroll Deducted and Other Group Premium Payment for Insurance Products (820) is a standard format for payroll deductions and premium payments for insurance products.


Pricer or Repricer A Pricer or Repricer is a person, an organization, or a software package that reviews procedures, diagnoses, fee schedules, and other data to determine the eligible amount for a given health care service or supply. Additional criteria can be applied to determine the actual allowance or payment amount.

Provider Taxonomy Codes

The Provider Taxonomy Codes are a category of administrative codes for identifying the provider type and area of specialization for all health care providers. A given provider can have several Provider Taxonomy Codes. This code set is used in the X12 standard Health Care Services Review (278) and the X12 standard Health Care Claim (837) transactions, and is maintained by the National Uniform Claim Committee (NUCC).

For more information: www.wpc-edi.com/codes/Codes.asp

S Segment A segment is a group of related data element s in a transaction.

[45 C.F.R. § 162.103]


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http://www.wpc-edi.com/codes/Codes.asp



Term Definition

Standard Transaction

A Standard Transaction is a transaction that complies with the applicable standard adopted under the Transactions and Code Sets (TCS) Rule regulations.

[45 C.F.R. § 162.103]

Strategic National Implementation Process (SNIP)

The Strategic National Implementation Process (SNIP) is a Workgroup for the Electronic Data Interchange (WEDI) program to help the health care industry identify and resolve HIPAA implementation issues.

For more information: www.snip.wedi.org

T Trading Partner A Trading Partner is an external entity with which business is conducted, e.g., a customer with whom data is exchanged. This relationship can be formalized via a Trading Partner Agreement (TPA). (Note: A trading partner of an entity for some purposes may be a business associate of the same entity for other purposes.)


Transaction Change Request System

The Transaction Change Request System is a system established under HIPAA for accepting and tracking change requests for any of the HIPAA mandated transaction standards via a single web site. There is an online process to enter your requests to the above DSMO’s. The following links provide more information on this process based on the type of Change Request you are submitting.

If you are sending in a request for a Healthcare Common Procedure Coding System (HCPCS) the process is explained here: http://cms.hhs.gov/medicare/hcpcs/04infopktweb.pdf

The Medicaid HCPCS process is defined here: http://cms.hhs.gov/states/hcpcs.asp

The Place of Service (POS) process is defined here: http://cms.hhs.gov/states/posreqst.asp

For more information: HIPAA - Health Insurance Portability and Accountability Act of 1996 or www.hipaa-dsmo.org.

Transactions and Code Sets (TCS)

The Transactions and Code Sets (TCS) Rule mandates uniform electronic interchange formats and code sets for all covered entities,


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http://www.hipaa-dsmo.org/



http://cms.hhs.gov/states/posreqst.asp

http://cms.hhs.gov/states/hcpcs.asp

http://cms.hhs.gov/medicare/hcpcs/04infopktweb.pdf



http://www.snip.wedi.org/


Term Definition

Rule and has been issued via regulations by the U.S. Department of Health and Human Services (HHS).

Standards within the TCS Rule have been selected from among the preexisting TCS specifications of a variety of non-governmental Designated Standards Maintenance Organizations (DSMOs), who will retain the primary responsibility for keeping these standards current as changes are needed.

The transactions specified in the Rule are:

270 Eligibility inquiry

271 Eligibility response276 Claim status request277 Claim status response

278Health Care Services Review - Request for Review and Response

820 Premium payment834 Enrollment/disenrollment835 Remittance advice837 Claim form

The code sets specified in the Rule are discussed under the definition of code sets.

For more information: www.cms.hhs.gov/hipaa/hipaa2/regulations/transactions/default.asp

[45 C.F.R. Parts 160 & 162]

Translator A Translator is a software tool for accepting an Electronic Data Interchange (EDI) transmission and converting the data (transactions or code sets) into another format, or for converting a non-EDI data file into an EDI format for transmission, or a software tool used to change non-standard transactions into HIPAA standard transactions and vice-versa.


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http://www.cms.hhs.gov/hipaa/hipaa2/regulations/transactions/default.asp


Term Definition

U

UB-82 The UB-82 is a uniform institutional claim (paper) form developed by the National Uniform Billing Committee (NUBC) that was in general use from 1983 – 1993.

UB-92 The UB-92 is a uniform institutional claim (paper) form developed by the National Uniform Billing Committee (NUBC) that has been in general use since 1993.

Uniform Bill (UB) A Uniform Bill (UB) is a bill that must be in a uniform format, as in UB-82 and UB-92.

Uniform Claim Form (UCF)

A Uniform Claim Form (UCF) is a professional claim form, as in Health Care Financing Administration-1500. The maintenance responsibilities belong to the National Uniform Claim Committee (NUCC).

For more information: www.nucc.org/1500-FAQ.html

W

Washington Publishing Company (WPC)

The Washington Publishing Company (WPC) is the company that publishes X12 standard HIPAA implementation guides and hosts the Electronic Healthcare Network Accreditation Commission (EHNAC) Standard Transactions Format Compliance System (STFCS) testing program.

For more information: www.wpc-edi.com/Default_40.asp

Workgroup for Electronic Data Interchange (WEDI)

The Workgroup for Electronic Data Interchange (WEDI) is a health care industry group that supported HIPAA Administrative Simplification (A/S), and has a formal consultative role under HIPAA legislation. WEDI also sponsors the Strategic National Implementation Process (SNIP).

For more information: www.wedi.org & www.snip.wedi.org

X

X12 Standard See Accredited Standards Committee (ASC) X12.

XML Extensible Markup Language (XML) is the software language used for the Internet that improves the functionality of the Web by providing more flexible and adaptable information identification.


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http://www.snip.wedi.org/

http://www.wedi.org/


http://tm.wc.ask.com/r?t=c&s=a1&id=30780&sv=za5cb0dee&uid=0D5389905F4052B04&sid=1B58823A2CCF98C04&p=%2Flinks&o=0&u=http://www.nucc.org/1500-FAQ.html

covered functions

Documents