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HIPAA White Papers & Glossary
Glossary Health Insurance Portability and Accountability Act of 1996 (HIPAA): A Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information.Also known as the Kennedy-Kassebaum Bill, K2, or Public Law 104-191. 1. American National Standards (ANS): Standards developed and approved by organizations accredited by ANSI. 2. American National Standards Institute (ANSI): An organization that accredits various standards setting committees, and monitors their compliance with the open rule making process that they must follow to qualify for ANSI accreditation. HIPAA prescribes that the standards mandated under it be developed by ANSI accredited bodies whenever practical. X12 is the format of the transaction code sets. 3. Business Associate (BA): A person or organization that performs a function or activity on behalf of a covered entity, but is not part of the covered entity's workforce. A business associate can also be a covered entity in its own right 4. Business Partner (BP): A term used in HIPAA Privacy NPRM to identify organizations that perform business functions for a covered entity, and should therefore be required to accept the same obligations for protecting any individually identifiable health care information that they receive from covered entity. 5. Chain of Trust (COT): A term used in the HIPAA Security NPRM for a pattern of agreements that extend protection of health care data by requiring that each covered entity that shares health care data with another entity require that entity provide protections comparable to those provided by the covered entity, and that entity, in turn, require that any other entities with which it shares the data satisfy the same requirements. 6. Claim Adjustment Reason Codes: A national administrative code set that identifies the reasons for any 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 in the X12 835 Claim Payment & Remittance Advice and the X12 837 Claim transactions, and is maintained by the Health Care Code Maintenance Committee. 7. Claim Attachment: Any of a variety of hardcopy forms or electronic records needed to process a claim in addition to the claim itself. 8. Code Set: Under HIPAA, this is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This includes both the codes and their descriptions. 9. Code Set Maintaining Organization: Under HIPAA, this is an organization that creates and maintains the code sets adopted by the Secretary for use in the transactions for which standards are adopted. Also see Part II, 45 CFR 162.103. 10. Coordination of Benefits (COB): A process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim. Also called cross over. 11. Covered Entity (CE): Under HIPAA, this is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction. 12. Designated Code Set: A medical code set or an administrative code set that HHS has designated for use in one or more of the HIPAA standards. 13. Designated Standard Maintenance Organization (DSMO): An organization that the Secretary has designated to maintain the standards; receive and process requests for adopting a new standard or modifying an adopted standard. 14. Electronic Data Interchange (EDI): This usually means X12 and similar variable length formats for the electronic exchange of structured data. It is sometimes used more broadly to mean any electronic exchange of formatted data. 15. HCFA Common Procedural Coding System (HCPCS): A medical code
set that identifies health care procedures equipment, and supplies for
claim submission purposes. It has been selected for use in the HIPAA transactions.
HCPCS Level I contains numeric CPT codes which are maintained by the AMA.
HCPCS Level II contains alphanumeric codes used to identify various items
and services that are not included in the CPT medical code set. 16. Health Care Clearinghouse: Under HIPAA, this is an entity that processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction, or that receives a standard transaction from another entity and processes or facilitates the processing of that information into nonstandard format or nonstandard data content for a receiving entity 17. Health Level Seven (HL7): An ANSI accredited group that defines standards for the cross platform. exchange of information within a health care organization. HL7 is responsible for specifying the LevelSeven OSI standards for the health industry. The X12 275 transaction will probably incorporate the HL7 CRU message to transmit claim attachments as part of a future HIPAA claim attachments standard. The HL7 Attachment SIG is responsible for the HL7 portion of this standard. 18. J Codes: A subset of the HCPCS Level II code set with a high order value of "J" that has been used to identify certain drugs and other items. The final HIPAA transactions and code sets rule states that these J codes will be dropped from the HCPCS, and that NDC codes will be used to identify the associated pharmaceuticals and supplies.(However, the most recent information indicates that J-Codes may remain.) 19. Local Code(s): A generic term for code values that are defined for a state or other political subdivision, or for a specific payer. This term is most commonly used to describe HCPCS Level III Codes, but also applies to state assigned Institutional Revenue Codes, Condition Codes, Occurrence Codes, Value Codes, etc. 20. National Association of State Medicaid Directors (NASMD): An association of state Medicaid directors. NASMD is affiliated with the American Public Health Human Services Association (APHSA). The Nation Medicaid EDI-HIPAA (NMEH) has been implemented under this organization to work on the EDI related HIPAA provisions. 21. National Committee on Vital and Health Statistics (NCVHS): A Federal advisory body within HHS that advises the Secretary regarding potential changes to the HIPAA standards. 22. National Council for Prescription Drug Programs (NCPDP): 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. 23. National Drug Code (NDC): A medical code set that identifies prescription drugs and some over the counter products, and that has been selected for use in the HIPAA transactions. 24. National Employer ID: A system for uniquely identifying all sponsors of health care benefits. 25. National Uniform Billing Committee (NUBC): An organization, chaired and hosted by the American Hospital Association, that maintains the UB 92 hardcopy institutional billing form and the data element specifications for both the hardcopy form and the 192 byte UB 92 flat file EMC format. The NUBC has a formal consultative role under HIPAA for all transactions affecting institutional health care services. 26. National Uniform Claim Committee (NUCC): An organization, chaired and hosted by the American Medical Association, that maintains the HCFA 1500 claim form and a set of data element specifications for professional claims submission via the HCFA 1500 claim form, the Professional EMC NSF, and the X12 837. The NUCC also maintains the Provider Taxonomy Codes and has a formal consultative role under HIPAA for all transactions affecting non dental non institutional professional health care services. 27. Office for Civil Rights: The HHS entity responsible for enforcing the HIPAA privacy rules. 28. Provider Taxonomy Codes: An administrative code set 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 278 Referral Certification and Authorization and the X12 837 Claim transactions, and is maintained by the NUCC. 29. Standard Transaction: Under HIPAA, this is a transaction that complies with the applicable HIPAA standard. 30. Standard Setting Organization (SSO): See Part II, 45 CFR 160.103. This is an organization accredited by ANSI that develops and maintains standards for information transaction or data elements, or any other standard necessary to implement the Electronic Transaction rule. 31. Strategic National Implementation Process (SNIP): A WEDI program for helping the health care industry identify and resolve HIPAA implementation issues. 32. Trading Partner Agreement (TPA): Under HIPAA, this is an agreement related to the exchange of information in electronic transaction, whether the agreement is distinct or part of a larger agreement, between each party to the agreement. 33. Transaction: Under HIPAA, this is the exchange of information between two parties to carry out financial or administrative activities related to health care. 34. Value-Added Network (VAN): A vendor of EDI data communications and translation services. 35. Washington Publishing Company (WPC): The company that publishes the X12N HIPAA Implementation guides and the X12N HIPAA Data Dictionary, and that also developed the X12 Data Dictionary. 36. Workgroup for Electronic Data Interchange (WEDI): A health care industry group that lobbied for HIPAA A/S, and that has a formal consultative role under the HIPAA legislation. WEDI also sponsors SNIP. 37. X12: An ANSI-accredited group that defines EDI standards for many American industries, including health care insurance. Most of the electronic transaction standards mandated or proposed under HIPAA are X12 standards. 38. X12 148: The X12 First Report of Injury, Illness, or Incident transaction. This standard could eventually be included in the HIPAA mandate. 39. X12 270: The X12 Health Care Eligibility & Benefit Inquiry transaction. Version 4010 of this transaction has been included in the HIPAA mandates. 40. X12 271: The X12 Health Care Eligibility & Benefit Response transaction. Version 4010 of this transaction has been included in the HIPAA mandates. 41. X12 275: The X12 Patient Information transaction. This transaction is expected to be part of the HIPAA claim attachments standard. 42. X12 276: The X12 Health Care Claims Status Inquiry transaction. Version 4010 of this transaction has been included in the HIPAA mandates. 43. X12 277: The X12 Health Care Claim Status Response transaction. Version 4010 of this transaction has been included in the HIPAA mandates. This transaction is also expected to be part of the HIPAA claim attachments standard. 44. X12 278: The X12 Referral Certification and Authorization transaction. Version 4010 of this transaction has been included in the HIPAA mandates. 45. X12 820: The X12 Payment Order & Remittance Advice transaction. Version 4010 of this transaction has been included in the HIPAA mandates.. 46. X12 834: The X12 Benefit Enrollment & Maintenance transaction. Version 4010 of this transaction has been included in the HIPAA mandates. 47. X12 835: The X12 Health Care Claim Payment & Remittance Advice transaction. Version 4010 of this transaction has been included in the HIPAA mandates. 48. X12 837: The X12 Health Care Claim or Encounter transaction. This transaction can be used for institutional, professional, dental, or drug claims. Version 4010 of this transaction has been included in the HIPAA mandates. 49. X12 997: The X12 Functional Acknowledgment transaction. (Not included in HIPAA mandates) 50. X12N: A subcommittee of X12 that defines EDI standards for the insurance industry, including health care insurance. Source: Workgroup for Electronic Data Interchange (WEDI) |
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