Search

Provider Update Newsletter

September 2003, Volume 131
 

All Providers

HIPAA Happenings
Enforcement Approach after October 16, 2003

Pharmacy Providers

Changes that Impact how NCPDP 5.1 claims process in MMIS
On-line Secondary Billing and Other Coverage Codes
Secondary billing and Maintenance Medication Quantity/Days Supply Editing

HIPAA Happenings

Trading Partners and Trading Partner Agreements

Who is a Trading Partner?

A Trading Partner is anyone who..

• Submits claims electronically through PES, billing agent, or other software; or
• Is a provider or billing agent and verifies patient eligibility through the RI Medicaid Portal; or
• Checks claim status through the Medicaid Portal; or
• Is a Clearing House and bills electronically (i.e. – WebMD); or
• Is a pharmacy provider who will check NDCs through the Medicaid Portal; or
• Is a provider or billing agent that will check remittance advice payments.

What is a Trading Partner Agreement (TPA)?

The Trading Partner Agreement (TPA) is an agreement between EDS, the fiscal agent for the RI DHS, and the billing provider, clearinghouse, or billing service. The TPA states that both parties agree to directly exchange electronic data between one another in the HIPAA standardized format (ANSI ASC X12N version 4010A). 

The TPA must list all RI Medicaid Provider Numbers, for whom the Trading Partner: submits electronic claim(s), accesses electronic remittance advice(s), checks claim status and/or checks eligibility status. RI Medical Assistance providers who utilize a Third Party to exchange data with EDS, must identify the transactions that the Third Party is authorized to perform on their behalf, and indicate Consent by an authorized signature on the TPA. Once the TPA and testing have been completed a Trading Partner ID will be assigned. You will receive written notification of your Trading Partner ID and password. 

Why do I need to sign the TPA?

If you are any business entity that will exchange electronic data with Rhode Island Title XIX and/or utilize the new functionality available through the RI Medicaid Web Portal, a TPA will need to be completed with EDS as the fiscal agent for DHS. The web interface will allow for uploading of claims, downloading of remittances, interactive claim status and eligibility verification, NDC look up, and prior authorization status. 
The HIPAA regulation suggests the use of a Trading Partner Agreement to ensure the integrity of the information being shared and to establish the intended use of protected health information that is being shared between covered entities (such as DHS and it providers).

>>Failing to complete and return the TPA may result in unintentional processing and payment delays of your claims. 

The HIPAA regulation suggests the use of a Trading Partner Agreement to ensure the integrity of the information being shared and to establish the intended use of protected health information that is being shared between covered entities (such as DHS and it providers).

Where do I sign the TPA?

Please sign the TPA on Page 7 under the section entitled, “Trading Partner Execution”. Signing your agreement on page 6, will not successfully execute the agreement between your organization and EDS and may cause additional delays.

>>Only original signatures will be accepted. No signature stamps please
>>Please recall that facsimiles or photocopies of the signed agreement will NOT be accepted
>>Call the EDI Help Desk now if you are experiencing problems with preparing the TPA or preparing for compliance to avoid delays in processing and payments.

What if I have to make changes or additions to my TPA after it is signed and submitted?

Once a Trading Partner Agreement (TPA) is received and processed, this form may be used to add additional billing providers to the original TPA ID assigned. The form is attached to end of this mailing for your convenience.

>>Only original signatures will be accepted. No signature stamps please.
>>Please remember that facsimiles or photocopies will NOT be accepted

What if my vendor or I will not be HIPAA compliant by October 2003?

Providers are required to be HIPAA compliant October 16, 2003 If you or your vendor will not be able to make the compliance deadline, the RI Provider Electronic Solution software will be available to download form the DHS website.

What are the minimum requirements for using PES?

NOTE: Recall that the current version of the Provider Electronic Solutions (PES) software provided by EDS is not HIPAA compliant and you will be required to sign a TPA before receiving the new version.
The minimum and recommended requirements for using PES are as follows:

Minimum Requirements:

• Pentium Processor
• Windows 98
• 64 MB RAM
• 800 x 600 monitor resolution
• 9600 baud rate modem or faster is preferred
• CD ROM is preferred
• Printer is preferred

Recommended:

• Windows 2000, Windows NT, and Windows XP
• 128 MB RAM
• 1024 x 768 monitor resolution
• 9600 baud rate modem or faster is preferred
• CD ROM drive
• Printer is preferred

Where can I go for more information on how HIPAA will affect me?

• Read the provider mailings, which contain important information and common questions.
  >>Refer to the June 25, 2003 mailing for more information on HIPAA and Trading Partner Agreements.
• Visit the Rhode Island DHS Web Site it is available for Rhode Island Medicaid Companion Guides (non-PES providers and billing agents), or you can receive the Companion Guide by mail once your Trading Partner Agreement is completed and submitted.
• Call the EDI Help Desk at 1-800-399-0835

Enforcement Approach after October 16, 2003

Enforcement Approach 

The Secretary has made the Centers for Medicare & Medicaid Services (CMS) responsible for enforcing the electronic transactions and code sets provisions of the law. 
CMS will focus on obtaining voluntary compliance and use a complaint-driven approach for enforcement of HIPAA’s electronic transactions and code sets provisions. When CMS receives a complaint about a covered entity, it will notify the entity in writing that a complaint has been filed. Following notification from CMS, the entity will have the opportunity to 1) demonstrate compliance, 2) document its good faith efforts to comply with the standards, and/or 3) submit a corrective action plan. 

Demonstrating Compliance - Covered entities will be given an opportunity to demonstrate to CMS that they submitted compliant transactions. 

Good Faith Policy - CMS’s approach will utilize the flexibility granted in section 1176(b) of the Social Security Act to consider good faith efforts to comply when assessing individual complaints. Under section 1176(b), HHS may not impose a civil money penalty where the failure to comply is based on reasonable cause and is not due to willful neglect, and the failure to comply is cured with a 30-day period. HHS has the authority under the statute to extend the period within which a covered entity may cure the noncompliance “based on the nature and extent of the failure to comply.” 

CMS recognizes that transactions often require the participation of two covered entities and that noncompliance by one covered entity may put the second covered entity in a difficult position. Therefore, during the period immediately following the compliance date, CMS intends to look at both covered entities’ good faith efforts to come into compliance with the standards in determining, on a case-by-case basis, whether reasonable cause for the noncompliance exists and, if so, the extent to which the time for curing the noncompliance should be extended. 

CMS will not impose penalties on covered entities that deploy contingencies (in order to ensure the smooth flow of payments) if they have made reasonable and diligent efforts to become compliant and, in the case of health plans, to facilitate the compliance of their trading partners. Specifically, as long as a health plan can demonstrate to CMS its active outreach/testing efforts, it can continue processing payments to providers. In determining whether a good faith effort has been made, CMS will place a strong emphasis on sustained actions and demonstrable progress. 
Indications of good faith might include, for example, such factors as:

• Increased external testing with trading partners.
• Lack of availability of, or refusal by, the trading partner(s) prior to October 16, 2003 to test the transaction(s) with the covered entity whose compliance is at issue. 
• In the case of a health plan, concerted efforts in advance of the October 16, 2003 and continued efforts afterwards to conduct outreach and make testing opportunities available to its provider community

While there are many examples of complaints that CMS may receive, the following is one example that illustrates how CMS expects the process to work. 
Example: A complaint is filed against an otherwise-compliant health plan that accepts and processes both compliant and non-compliant transactions while working to help its providers achieve compliance.
In this situation, CMS would 

1) notify the plan of the complaint
2) based on the plan’s response to the notification, evaluate the plan’s efforts to help its noncompliant providers come into compliance 
3) if it determined that the plan had demonstrated good faith and reasonable cause for its non-compliance, not impose a penalty for the period of time CMS determines is appropriate, based on the nature and extent of the failure to comply.

For example, CMS would examine whether the health plan undertook a course of outreach actions to its trading partners on awareness and testing, with particular focus on the actions that occurred prior to October 16th. Similarly, health care providers should be able to demonstrate that they took actions to become compliant prior to October 16th. If CMS determines that reasonable and diligent efforts have been made, the cure period for noncompliance would be extended at the discretion of the government. Furthermore, CMS will continue to monitor the covered entity to ensure that their sustained efforts bring progress towards compliance. If continued progress is not made, CMS will step up their enforcement efforts towards that covered entity. 
Organizations that have exercised good faith efforts to correct problems and implement the changes required to comply with HIPAA should be prepared to document them in the event of a complaint being filed. This flexibility will permit health plans to mitigate unintended adverse effects on covered entities’ cash flow and business operations during the transition to the standards, as well as on the availability and quality of patient care.

Corrective Action Plan (CAP) – After October 16, 2003, in addition to possible fines and penalties imposed, CMS will expect non-compliant covered entities to submit plans to achieve compliance in a manner and time acceptable to the Secretary. More detailed information on CAPs will be forthcoming.

Working Toward Compliance

In the few remaining months before the October 16th deadline, HHS encourages health plans and providers to intensify their efforts toward achieving transaction and code set compliance. In addition, HHS encourages health plans to assess the readiness of their provider communities to determine the need to implement contingency plans to maintain the flow of payments while continuing to work toward compliance. Although transaction and code set compliance is a huge undertaking, the result will be greatly enhanced electronic communication throughout the health care community. Successful implementation will require the attention and cooperation of all health plans and clearinghouses, and of all providers that conduct electronic transactions. There is considerable industry support for transaction and code sets, and we all look forward to realizing the many advantages of its successful implementation.

Need More Information

Refer to the complete guidance on enforcement published by The Centers for Medicare & Medicaid Services