Medicare Compliance & Reimbursement

Most Medicare claims aren't HIPAA compliant.

It's a good thing the Centers for Medicare & Medicaid Services implemented a Health Insurance Portability and Accountability Act contingency plan.

Health care providers clearly need the grace period. According to recent CMS statistics, less than half - 48.4 percent - of Medicare electronic claims submit

ted between Nov. 10 and Nov. 14 were compliant with the HIPAA transactions and code sets standards.

According to CMS, the following are the top 9 problems that have emerged during HIPAA claims testing with Medicare contractors:

            1. Errors in data element NM109 (the provider's social security number or employer tax ID number).

            2. Enveloping issues - ISA and GS segments.

            3. Invalid taxonomy codes (approved codes are at www.wpc-edi.com/codes).

            4. Invalid characters in the data stream.

            5. Missing SBR (subscriber) data elements, such as date of birth and gender.

            6. Missing or out-of-order N3 (street address) and N4 (city, state and zip) segments.

            7. Missing submitter contact phone number.

            8. Sending both the billing provider loop and the rendering provider loop when they are the same entity.

            9. Invalid date formats.

To see CMS' guidance on these issues, go to http://cms.hhs.gov/providers/edi/.

Lesson Learned: CMS' HIPAA contingency plan won't remain in effect forever, so providers should work hard to make sure they're complying with the transactions rule.