Provider FAQ Archive - 2002 MQD FAQ Archive - 2002 MQD Archive - 2003

Provider FAQ Archive - 2002

Q: What are the HIPAA deadlines?
A: Health care payers and providers which conduct any of the named transactions electronically must comply with the following deadlines:

• You must comply with the HIPAA privacy Rule by April 14, 2003.
• You must comply with the HIPAA electronic transactions regulations by October 16, 2002, unless you filed an extension.
• If you filed the Standards Model Compliance Plan, you must begin testing by April 16, 2003, and be compliant by October 16, 2003.

Please note that Med-QUEST assumes no responsibility for interpretation of the rules or for compliance of any provider or payer. Each provider and payer is responsible for reading and understanding the rules to assess compliance requirements.

Q: Can’t I just avoid the whole thing?
A: No. Med-QUEST urges all providers to read and understand the privacy rules. HIPAA affects all health care providers and payers.

Even if you submit paper claims, you are still affected by HIPAA transactions and code sets. At a minimum, you should review the revised provider manuals and/or attend training. The training will inform you of any billing changes mandated by the elimination of local codes or other HIPAA legislation.


Q: Will the Provider and Health Plan manuals be updated?
A: Yes. The manuals will be updated to reflect HIPAA changes. These updates will be available in early Fall 2003.


Q: How will I submit claims under HIPAA?
A: You can submit paper or electronic claims, just as you do now. If you submit electronic claims you must ensure that the format of your electronic claims is HIPAA-compliant. If you contract with a third party billing service or clearinghouse, contact them to be certain they will be HIPAA-compliant by the October 2003 deadline.

You must also sign and return a trading partner agreement if you intend to submit claims electronically. Keep checking this Web site throughout 2003; we will keep you informed about the process for receiving, signing, and returning trading partner agreements.


Q: Who is responsible for training providers?
A: ACS, Hawaii Medicaid’s fiscal agent, will provide training prior to October 16 on billing changes related to the implementation of HIPAA transactions and code sets. There will be no training by MQD on Privacy for providers.


Q: I am a physician. I do not own a computer. Do I have to buy a computer?
A: There is no requirement under HIPAA that you must own a computer. However, you may want to investigate purchasing a computer, which will enable you to submit and receive electronic transactions. In the future, this is likely to become the standard means for managing healthcare business.

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Q: Why shouldn’t I just drop my claims to paper?
A: Providers who file electronically recognize significant benefits:

• Faster claims payment
• Pre-edits for common errors
• Reduce data entry errors and delays caused by keying and scanning
• Provide acknowledgement of receipt
• Eliminate costs of handling and storing paper

Electronic claims are also much less expensive for Med-QUEST to process, which helps us manage expenditures and ensures more program dollars are devoted to services to clients.

Q: As long as I submit on paper, won’t I be exempt from privacy rules?
A: All health care payers and providers are subject to privacy rules if they conduct any of the named transactions electronically. You may decide to submit paper claims to one or more health care payors. However, other payors may require your organization to submit electronically by contract. Therefore, Your organization must conduct the necessary assessment to determine the impact of HIPAA privacy rules to your organization’s current practices. An assessment will identify the various business interactions between your organization and other organizations that are either covered or non covered entities under the Privacy rule.

Please note that submission of paper claims requires more time, effort, and resources to process for your organization and the state. If you submit a paper claim, the manual intervention required to process a paper claim will take considerably longer to complete and will delay the payment of your claim unnecessarily.

Q: What is a transaction?
A: ‘Transaction’ refers to standardized electronic exchanges of information, such as an electronically submitted claim or an electronic remittance advice. Transactions may originate with the payer (in this instance, Medicaid or a health plan) or with the provider.

Q: How many types of transactions are there?
A: The following mandated transactions have been identified as part of HIPAA for Hawaii Medicaid:

• 834 Enrollment and maintenance
• 820 Premium payment for insurance products
• 270/271 Eligibility inquiry and response
• 837 Claim information related to Professional (P), Institutional (I), or Dental (D) services
• NCPDP 5.1 Retail Pharmacy claim information
• 835 Remittance Advice
• 276/277 Claim status and response
• 278 Requests for review and response (authorizations)

Not all providers will send or receive all the transactions listed above. Your software vendor or clearinghouse will receive detailed programming specifications for the relevant transactions.

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Q: I use third party software or a clearinghouse to submit and receive electronic claims, eligibility verification requests, and/or remittance advices. Is Medicaid responsible for informing my vendor about HIPAA requirements?
A: No. Medicaid is responsible only for its own compliance, as is every other payer, provider, and business associate.

However, Med-QUEST is committed to working with providers and their vendors or clearinghouses to provide for uninterrupted electronic transmissions. We urge you to contact your billing software vendor to determine whether they intend to be HIPAA compliant. Please direct them to this Web site, where we will continuously post updates and provide important information.

Q: If a vendor or clearinghouse has received a certification from an independent HIPAA electronic transaction testing service, such as CLAREDI, do you require additional certification or just communication testing?
A: Yes. Business to Business testing for our processing rules (e.g. provider number format) is still required. HIPAA compliance is only one piece of the certification process.

We will conduct further testing with those vendors, developers, and clearinghouses that have been certified to Level 5 by a recognized certification testing site.

Q: What happens if my software vendor is not ready by the deadline?
A: After October 16, Med-QUEST will not accept electronic transactions, such as claims, from submitters who are not certified HIPAA-compliant. If your software vendor is not ready, you have several options:

• Contract with a certified vendor which has tested with Med-QUEST
• Contract with a clearinghouse, which can take the electronic output from your software vendor and translate it into HIPAA-compliant transactions. Please note that the clearinghouse must have tested with Med-QUEST
• Submit claims on paper until your vendor is ready

Please note that paper claims requires more time, effort, and resources

Q: What is an Implementation Guide?
A: An Implementation Guide provides the official mapping specifications for each transaction. See Electronic Health Transaction Standards for more information.

Q: What is a Companion Document?
A: A Companion Document, also referred to as a Companion Guide, is a supplement to the HIPAA Implementation Guide. The Implementation Guide for each mandated transaction describes the formatting rules, including syntax and structure. The Companion Document further defines the Implementation Guide so the data transferred can be understood by HPMMIS. For example, the Implementation Guide dictates where the provider ID must be included in the transaction, but the Companion Document will tell you that Med-QUEST requires eight-digit numeric provider ID.

Even if vendors say they are HIPAA-compliant and certified, they must obtain Med-QUEST’s Companion Documents to ensure they can submit electronic transactions to the HPMMIS.

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Q: The Companion Documents look complicated to me. Am I required to understand the information contained in them?
A: Most of the Companion Guides, and the Implementation Guides upon which they’re based, are written for software developers. Most providers, or most users of the billing software, will see only the final software package.

For this reason, Med-QUEST urges providers to communicate with their software developers or clearinghouses. Ask your vendor whether they have downloaded the Companion Documents from the Med-QUEST Web site. Instruct them to visit the Web site frequently. Med-QUEST will be available to answer vendor questions and is committed to conducting testing with contracted vendors to ensure they are ready to submit transactions to Med-QUEST by October 16th.

Please note that any software developer is welcome to download the Companion Documents, visit the Web site, and ask questions; however, Med-QUEST will test only with those vendors that are contracted with Hawaii Medicaid providers.

Q: What if a vendor tells me their product is ‘HIPAA Compliant’?
A: Understand that HIPAA compliant does not necessarily mean the vendor can transmit transactions with Med-QUEST. A vendor must obtain a copy of the relevant Companion Document(s) to ensure its data can be transmitted to and understood by the HPMMIS. Providers must understand that Med-QUEST will test only with those vendors who have contracts with Hawaii Medicaid providers.

Also, be aware that the provider of services, not the contracted vendor, is ultimately responsible for being HIPAA-compliant. Make sure you work closely with your vendor to understand your rights and responsibilities regarding HIPAA compliance. This may have special importance regarding HIPAA Privacy and Security rules.

Q: What is a code set?
A: Under HIPAA, a "code set" is any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnosis codes, or medical procedure codes.

Medical data code sets used in the health care industry include the following:

• Coding systems for disease, impairment, or other health related problems, and their manifestations
• Causes of injury, disease, impairment, or other health-related problems
• Actions taken to prevent, diagnose, treat or manage diseases, injuries, and impairments
• Any substances, equipment, supplies, or other items used to perform these actions.

Code sets for medical data required for data elements in the administrative and financial health are transaction standards adopted under HIPAA for diagnoses, procedures, and drugs.

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Q: How will use of standardized code sets change my billing procedures?
A: Med-QUEST will provide a crosswalk of local codes to HCPCS in May 2003. The crosswalk will be posted on the Web site.

ACS, Hawaii Medicaid’s fiscal agent, will conduct provider training for fee for service providers. We will update the provider manuals for any any billing changes resulting from transactions and code sets compliance.

Q: What about locally assigned procedure codes, like those for EPSDT or other Medicaid-specific services?
A: Effective October 16, 2003, there will be no local codes. Med-QUEST will provide a crosswalk of local codes to HCPCS in May 2003. The crosswalk will be posted on the Web site.


Q: When will I have to stop using locally assigned codes I currently use for billing?
A: Use of local codes will be based on date of service. Med-QUEST will inform providers, through training, newsletters, and updated manuals, of billing changes related to local codes.

Q: What is the difference between a business associate and a trading partner?
A: A trading partner agreement is required by the Transactions and Code Sets Rule and covers those health plans and providers that conduct electronic transactions with Med-QUEST. The agreement must cover how the partner will implement the new transactions and code set formats. A business associate is an entity that conducts services on behalf of Med-QUEST and uses, creates, maintains, transmits, or discloses protected health information (PHI) of Med-QUEST recipients. A BA contract or contract addenda is needed to assure that the BA is protecting the PHI according to HIPAA Privacy requirements. There will be cases in Hawaii where a BA is not a trading partner; however many trading partners will also be a BA.

Q: Am I a business associate or a trading partner to Med-QUEST? Who made that determination?
A: That depends on the nature of your relationship, activities, and business interactions with Med-QUEST.. Med-QUEST has developed a Business Associate addendum and provider HIPAA requirement addendum that will be forwarded to the affected organizations.

Q: Why do we need to sign business associate and/or trading partner agreements?
A: The HIPAA rules mandate legally binding contractual agreements.

MQD FAQ Archive - 2002

Med-QUEST and ACS are pleased to work directly with software developers, clearinghouses, and vendors that are working towards electronic certification, or that currently support Med-QUEST providers by transmitting electronic transactions. It is important to note, however, that ACS will not conduct testing with anyone who is not an active Med-QUEST provider or an authorized representative of an active Med-QUEST provider.

Software developers encountering production problems with electronic transactions (claims and/or remittance advice) should contact the ACS Provider Call Center at (808) 952-5570 (O’ahu and mainland) or (800) 235-4378 (Neighbor Islands). They can also contact the ACS EDI Team via email at [email protected].

Software developers ready to begin the testing process on behalf of an active Med-QUEST provider should contact ACS. The ACS Provider Call Center will gather information from the caller and begin the registration process.

For more information, software developers are encouraged to access the Documents and Deliverables page, which contains applicable Companion Documents and other helpful information, and the 837/835 Testing page, which describes the testing process in detail.

MQD Archive - 2003

The HIPAA Transactions and Code Sets Contingency Plan Memo, dated September 11, 2003, enabled current electronic submitters that had not completed TCS testing to continue submitting in the legacy format until December 1, 2003.

Med-QUEST and ACS are aware that some providers and their software vendors require an extension beyond December 1st. If you are currently executing the contingency strategy (i.e., submitting claims and/or receiving Electronic Remittance Advice in the old format) and you have not contacted ACS to reschedule testing for the HIPAA-compliant transactions, please email the ACS EDI Team at [email protected].

Med-QUEST contracts with three private managed care organizations: AlohaCare, Kaiser, and HMSA. These health plans are considered trading partners to Med-QUEST for the purpose of sending and receiving HIPAA-mandated electronic transactions. The three health plans are:

• AlohaCare
• HMSA
• Kaiser Permanente

Med-QUEST and the QUEST health plans successfully implemented the 834 and 820 transactions, which went into production on November 1, 2003. Med-QUEST thanks the QUEST health plans for their efforts during the testing process and credits the team effort as key to the implementation success.

Health plans will be implementing the 837 Encounter implementation next. The planned implementation date is April 1, 2004. Med-QUEST has provided a draft Companion Document for the transaction, and regularly scheduled meetings will be conducted to review the document and address issues. Plans are encouraged to contact Med-QUEST directly for issues related to the 837 Encounter transaction.

For government agencies acting as health plans for Hawaii Medicaid, relevant information of the Draft 837 Encounter Companion Document was distributed to Health Plans in November. Please access the Documents and Deliverables page to download a copy of the document. Med-QUEST strongly encourages plans to review and comment as soon as possible

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