Under both the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Gramm-Leach-Bliley Act, LifeWise must take measures to protect the privacy of our members’ personal information. In addition, other state and federal privacy laws
may provide additional privacy protection. Personal information includes the member’s name, Social Security number, address, telephone number, account number, employment, medical history, health records, and claims information. Learn more about our
member privacy practices.
Here you’ll find HIPAA information specific to providers.
Resources
This section is for informational purposes only and is not intended as legal advice. It is an overview and is not comprehensive. LifeWise makes no representations or guarantees that the information concerning HIPAA is accurate or complete. Please contact
your attorney for legal advice.
Administrative Simplification
The Administrative Simplification part of HIPAA aims to reduce administrative costs in the healthcare industry through adopting and using standardized, electronic transmission of administrative and financial data.
Benefits of Administrative Simplification
- Reduces overall healthcare costs
- Standardizes many administrative tasks in the healthcare industry
- Protects against fraudulent billing practices
- Protects individuals and their PPI
- Protects members' rights through greater access to their health information
- Potentially improves medical care through better data exchange between providers and payers
Administrative Simplification can be broken down into five key elements:
- Privacy
- Security
- Standardized Transactions
- Standardized Code Sets
- Unique Identifiers
Privacy
HIPAA privacy regulations require compliance with standards that protect the privacy of PPI. These rules include strict limits on how information can be used and disclosed.
Security
HIPAA's Administrative Simplification provisions also require compliance with security standards related to PPI that is transmitted or stored electronically. The regulations include requirements for physical, technical and procedural safeguards to keep
electronic healthcare information secure.
Standardized Transactions
Covered healthcare providers, healthcare payers and healthcare clearinghouses must use "standard" formats to exchange healthcare transactions electronically.
The standard formats for HIPAA transactions are the American National Standards Institute (ANSI) ASC X12N, Version 4010A1. These formats apply to the following common business functions:
| Transaction Name |
Number |
| Healthcare Claims |
837 |
| Healthcare Claim Payment/Advice |
835 |
Payroll Deducted and
Other Group Premium Payment |
820 |
| Benefit Enrollment and Maintenance |
834 |
| Healthcare Services Review |
278 |
| Healthcare Eligibility Benefit Inquiry and Response |
270/271 |
| Healthcare Claim Status Request and Response |
276/277 |
Standardized Code Sets
Electronic data exchange requires using standard code sets. The medical code sets used to identify data include:
- ICD-9 for diseases
- CPT-4 for services and procedures
- HCPCS for medical equipment, injectable drugs and transportation services
- NDC for prescription drugs
- CDT-3 for dental services
The non-medical code sets include codes for place of service, revenue codes, relationship codes and more.
Unique Identifiers
There are standard national identifiers for providers and employers. These "unique identifiers" will permit electronic data exchange and matching for all health insurance related transactions.
NPI Compliance
You should include your NPI number now in HIPAA standard electronic transactions. Your Tax Identification Number (TIN) is still required for the ‘Bill To’ or ‘Pay To’ provider.
Refer to the Centers for Medicare and Medicaid Services (CMS)
National Provider Identifier Standard (NPI) web site for information on:
- Applying for NPI Online
- Current news about NPI implementation for providers
- Links to educational resources
- Instructions on how to apply for an NPI
- “Medlearn Matters” articles on NPIs
You can request a printed application:
In addition, physicians and providers now have the ability to enter their NPI with specific demographic data through
OneHealthPort. The information will be shared in an electronic file to each of the participating health plans. At OneHealthPort, you can register with an ID and password if you do
not already have one, and access the link to the NPI entry area.