HIPAA/Affordable Care Act

HIPAA - Health Insurance Portability and Accountability Act

To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), included Administrative Simplification provisions that required HHS to adopt national standards for electronic health care transactions and code sets, unique health identifiers, and security. Congress also incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information. The Administrative Simplification and privacy rules were designed to improve the efficiency of the health care system by standardizing the electronic exchange of data and protect the security and privacy of member health information.

ICD-10

Effective October 1, 2015, health care providers, payers, clearinghouses, and billing services are required to comply with the transition to ICD-10, which means:

  • ICD-10 diagnosis codes will be used for all health care services.
  • ICD-10 procedure codes will be used for all hospital inpatient procedures. Please note that the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.
  • All electronic transactions must use Version 5010 standards.

For more information, review our ICD10 FAQ

5010

The HIPAA X12, version 5010, is a revised set of HIPAA electronic standards that have been adopted to replace previous versions of specific health care transactions. Covered entities, such as health plans, health care clearinghouses, and health care provides, are required to conform to HIPAA 5010 standards.

For more information, review our 5010 FAQ

NPI

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique numeric 10-digit identifier that is assigned by the Centers for Medicare & Medicaid Services (CMS). Covered health care providers must use the NPIs in the administrative and financial transactions adopted under HIPAA.

There are two types of NPI's that providers can apply for through the National Plan and Provider Enumeration System (NPPES):

  • Type 1 NPIs are issued to providers or individuals who render health care. Examples include: physicians; dentists; nurse practitioners; chiropractors; pharmacists; and physical therapists.
  • Type 2 NPIs are issued to health care providers and organizations. Examples include: hospitals; home health agencies; clinics; nursing homes; residential treatment centers; laboratories; ambulance companies; group practices; suppliers of durable medical equipment; and pharmacies.

For more information visit the US Department of Human Services and the Center for Medicare and Medicaid Services websites.


ACA - Affordable Care Act

The Administrative Simplification provisions of the Affordable Care Act of 2010 (ACA) build on the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Patient Protection and Affordable Care Act (PPACA) required HHS to issue operating rules for HIPAAs standard transactions, to make the information and transmission formats more uniform and reduces the role of plan-specific companion guides:

To obtain more information regarding HHS' final operating rules and compliance schedules, visit CMS' Website or CAQH CORE