HIPAA-AS
Questions and Answers
For general information about the regulations, visit the
U.S. Department of Health and Human Services web site on Administrative
Simplification. It has information on transactions, data standards,
privacy regulations and related topics.
Below are questions specific to Wellmark. Check frequently for
information updates.
Note: the material on this Web site is not legal advice and should not
be used as legal advice. If you need legal advice upon which you can rely,
we recommend you consult your attorney.
Obtaining Information from Wellmark
Q. I am an individual Wellmark customer calling with questions
about my claims. How do I obtain help over the phone with claims resolution?
A. Call the customer service number on your ID card and
be prepared to verify:
- Name, address, and ID number of the contract holder. (The ID number
often is the Social Security Number but not always).
- Name and date of birth of the patient
- Relationship to the contract holder if you are not contract holder
According to Wellmark policy, customer service will not release specific
diagnosis or procedure information over the phone to any party –
even to the individual patient.
We cannot discuss issues in more detail than you provide.
Q. Are there limits on what information can be provided to me
over the phone?
A. Yes. We cannot discuss issues in more detail than
you provide. Wellmark will not disclose the diagnosis, type of service
or treatment, the name of the clinicians or facilities involved.
Q. I am calling Wellmark on behalf of my spouse or family member
for help with claim resolution. How do I obtain help over the phone with
claims resolution?
A. Call the customer service number on your ID card
and be prepared to verify:
- Name, address, and ID number of the contract holder. (The ID number
often is the Social Security Number but not always).
- Patient’s name and date of birth
- Relationship of the patient to the contract holder
- Name and relationship to the patient
We cannot discuss issues in more detail than you provide. Wellmark will
not disclose the diagnosis, type of service or treatment or the name of
the clinicians or facilities involved.
If you have this information from the patient and you can confirm the
specific information related to the claim, Wellmark may further discuss
the situation as long as that explanation does not involve disclosing
additional protected health information for that patient.
Q. I want my spouse or a family member to be able to call Wellmark
to help with claims resolution for me. What do I need to do?
A. If you want your spouse or family member to help with
a single claim situation, you may complete an authorization
for that specific purpose.
If you want your spouse or family member to act on your behalf with respect
to all your individual rights concerning your protected health information,
then you may submit an authorized representative appointment form for Iowa
Q. Will Wellmark accept a verbal authorization from the patient?
A. Yes. If the patient is present when the family members
contacts Wellmark, we will accept a verbal authorization from the member
to discuss the issue during that call.
Q. How long does the authorization last?
A. An oral authorization applies only to the duration
of the phone call. A written authorization signed by the patient applies
for the period of time the patient indicates on the form.
Q. What does the section on disaster relief mean to me?
A. It means that Wellmark is allowed to share medical
information about you with a family member or government authorities without
your permission in the case of a disaster, such as a flood or tornado.
Q. To whom does Wellmark release my information?
A. You may give Wellmark written authorization to use
your medical information or to disclose it to anyone for any purpose.
This authorization is available in the Wellmark
Notice of Privacy Practice on the Wellmark
Web site.
We may disclose your information to a family member, friend or other
person to the extent necessary to help with your health care or with payment
for your health care. For example, if a family member verifies the name
of the provider, the date of service and the charge amount, we will discuss
the claim status, paid date and paid amount. We will not release your
diagnosis or the type of procedure or service you received.
Q. How do I get a list of companies or people to whom Wellmark
releases my information?
A. You have the right to receive a list of instances
in which Wellmark disclosed your medical information for purposes other
than our normal payment or health care operations. Please refer
to your Notice of Privacy Practices
under the section titled Disclosure Accounting for instructions on how
to obtain the list.
Q. What is a plan sponsor?
A. A plan sponsor is an employer or organization that
offers a group health plan to its employees or members. A plan sponsor
may be a director, senior executive, or other employee who does not require
access to enrollees’ health information to perform their day-to-day
job functions.
Q. What information does Wellmark release to the plan sponsor?
A. Typically Wellmark only releases “de-identified”
or aggregate summary health information to a plan sponsor. A plan sponsor
may also receive information concerning enrollment in the health plan.
Q. What information is contained in the medical information that
Wellmark releases?
A. For large group health plans, Wellmark may provide
aggregate health information showing how the plan members have utilized
the health plan. For example, a report we provide group health plans during
the annual renewal period shows the total amount of covered charges submitted
in claims for inpatient, outpatient, office and other health care in comparison
to the same categories for the prior year.
Wellmark Privacy Compliance
Q.Who do I contact if I have a privacy-related question or issue?
A. You may contact Wellmark's Privacy Office:
Mailing Address:
Wellmark, Inc.
Privacy Office, Station 850
636 Grand Avenue
Des Moines IA 50309-2565
Telephone:
877-610-6395 Outside Des Moines Area
515-299-5850 Des Moines Local Area
Email:
privacyoffice@wellmark.com
Web Site:
www.wellmark.com
Q. Does Wellmark intend to comply with all elements of the Privacy
Regulation, including the items listed below?
- Erection of physical barriers and electronic firewalls to safeguard
protected health information (PHI)
- Process to provide individuals with access to their PHI in a designated
record sets
- Process for individual to request an amendment to their information,
request restrictions and confidential communications
- Receipt of “authorizations” from individuals as needed
- Process for individuals to lodge complaints, handle complaints and
track complaint-resolution
- Reporting to customers any improper use or disclosure of PHI
- Requiring subcontractors and others to comply with HIPAA-AS privacy
regulations
- Retaining designated record sets according to applicable insurance
laws?
A. Yes. Please see Wellmark
Notice of Privacy Practices for additional information
Q. Has Wellmark published its policies and procedures regarding
HIPAA-AS privacy compliance?
A. Yes. Please see Wellmark
Notice of Privacy Practices for additional information
Q. Is Wellmark’s Notice of Privacy Practices available upon
request?
A. Yes. Please see Wellmark
Notice of Privacy Practices for additional information
Q. How will Wellmark respond to my request to inspect, copy or
change my protected health information or receive an accounting of disclosures
after April 14, 2003?
A. How the individual obtains the PHI depends on whether
he/she is covered under a fully-insured health plan or a self-funded health
plan arrangement. Please read the next two questions.
If you are enrolled in a fully insured plan:
To inspect, copy or change information: Wellmark customers
will submit their requests to Wellmark. The request process is outlined
in the Wellmark Notice of Privacy
Practices.
To request a designated record set: Wellmark customers will
submit their requests to Wellmark. Wellmark will charge the member of
a fully-insured health plan a cost-based fee for each request. The fee
will be requested at the time the request is submitted. The request
process is outlined in the Wellmark
Notice of Privacy Practices.
To receive an accounting of disclosures: Customers
will submit their requests to Wellmark. Wellmark will provide the first
accounting in a 12-month period at no charge to the member. For each
additional request, Wellmark will charge the customer a cost-based fee
for each request. The fee will be required at the time the request is
submitted. The request process is outlined in the Wellmark
Notice of Privacy Practices.
If you are in a self-insured group health plan:
The customer should contact that health plan which will have its own
procedures for answering the requests. The customer may want to contact
his/her Human Resources department for information.
Q. How do I know if my health plan is fully insured or a self-funded
health plan with Wellmark?
A. If you receive a Notice of Privacy Practices from
Wellmark, you have fully insured plan with Wellmark You also can contact
your employer’s Human Resources department
Notice of Privacy Practices
Q. Who is supposed to receive the Wellmark Notice of Privacy Practices?
A. Wellmark is sending its Notice of Privacy Practices
to contract holders who are enrolled through fully-insured health plans,
including direct-pay or Medicare Supplement plans.
Individuals enrolled in self-funded health plans will receive a Notice
of Privacy Practices document from those self-funded group health plans.
Q. Will Wellmark send me more than one Notice of Privacy Practices?
A. Wellmark sent one copy of its Notice of Privacy
Practices to each enrolled contractholder by April 14, 2003. After that,
we must provide the Notice to each new contractholder upon enrollment,
and Wellmark must advise its contract holders of the availability of
the Notice every three years.
You might receive a Notice from Wellmark and a Notice from another insurance
plan if your health plan benefits are provided by more than one plan.
Q. Does Wellmark send the Privacy Notice for its fully-insured
accounts?
A. Yes.
Q. Does Wellmark send the Privacy Notice for its self-funded
accounts?
A. No.
Q. Does Wellmark require a review of the privacy policies and
procedures for self-funded accounts?
A. No.
Wellmark Transaction/Code Set Compliance
Q. When did the HIPAA-AS transaction and code set regulations
go into effect for Wellmark?
A. October 16, 2003
Q. Which electronic formats does Wellmark transmit
or receive now?
A.
820-Premium Payment
834–Member Enrollment and Maintenance
835-Electronic Remittance Advice
837I-Institutional claim
837D–Dental claim
837P-Professional claim
270/271-Eligibility Inquiry/Response
276/277-Claim Status Inquiry/Response
278-Preauthorization/Precertification/Referral
Q. Does Wellmark accept transmissions
from plan sponsors in their current formats? (examples: enrollment,
disenrollment or premium payment)
A. Yes.
Q. Will plan sponsors be charged additional fees for non-EDI
standard transmissions?
A. No.
Format 834: Benefit Enrollment and Maintenance
Q. How is Wellmark handling testing for the 834?
A. Enrolled groups have an opportunity to simplify their enrollment
process with the use of Electronic Transaction 834 - Benefit Enrollment
and Maintenance.
This electronic format includes information on member demographics, changes
in enrollment information, and allows a group to enroll, dis-enroll or
re-enroll members electronically. The 834 format replaces many non-standard
data formats now used and will become the industry standard.
Using the 834 simplifies the enrollment process, and includes all the
fields Wellmark now uses on paper applications.
Transaction Rule Requirements
Q. What are the transactions affected by the HIPAA-AS
rules?
A. The standard transaction formats and their ANSI ASC designations
under HIPAA-AS rules are:
- Health claims - 837 Institutional, 837 Professional, and 837 Dental
- Health care payments and remittance - 835
- Coordination of benefits - 837 COB
- Health claim status inquiry and response - 276 and 277
- Enrollment or disenrollment in a health plan - 834
- Eligibility verification and benefit inquiry and response - 270 and
271
- Premium payments - 820
- Referral certification and authorization - 278
Q. What are the code sets specified by the HIPAA-AS
rules?
A. The code sets specified by HIPAA-AS rules are:
| Current Procedural Terminology (CPT-4) |
Practitioner services |
| ICD-9-CM, Volumes 1&2 |
Diseases
Injuries
Other health problems
Impairments
Causes |
| ICD-9-CM, Volume 3 |
Diagnosis Management
Prevention Treatment |
| NDC |
Drugs
Biologies |
| Current Dental Terminology
(CDT-4) |
Dental Services |
| HCPCS - Level 2 |
Physician Services
Physical Occupational Therapy
Radiology Services
Lab Tests
Other Medical Diagnostics Procedures
Hearing and Vision
Transportation Services
Prosthetic Devices
Medical Supplies
Orthotic Devices
Durable Medical Equipment |
Q. What codes does Wellmark accept?
A. Under HIPAA-AS, providers must submit and carriers must accept
only VALID codes from these national code sets. Wellmark Blue Cross
and Blue Shield began over two years ago to eliminate "local"
codes - codes designed by carriers for specific benefit processing.
The intent of the HIPAA-AS legislation is to ensure that only nationally
recognized coding will be used to simplify the claims submission and adjudication
process among carriers and providers.
Q. Are there code sets that are not specified by the
HIPAA-AS rules?
A. Yes. Two common code sets not specified by the rules are: Anesthesiology
Society of America (ASA) and the Diagnostic and Statistical Manual of
Mental Disorders - Fourth Edition (DSM-IV) [note: although the DSM-IV
is not designated, the information in these codes also is included in
the ICD-9-CM codes which are specified by the HIPAA-AS rules.] The ASA
and DSM-IV codes are not accepted as standard code sets.
Q. Does HIPAA-AS require carriers to process claims
or offer benefits to groups in a certain way?
A. No. HIPAA-AS does not require carriers to process claims
or offer benefits to groups and individuals in any fixed manner.
However, the concept of accepting a standard claims format with standard
codes does not prevent carriers from making unique adjudication decisions
based on the variety of benefits programs available to the public.
Q. Does HIPAA-AS require me to send claims or other
transactions electronically?
A. No. If you do not send electronic transactions today, you are not
required to begin. However, if you send any of the covered transactions
electronically, you must follow the Transactions and Code Sets rules.
Q. How does HIPAA-AS affect the paper claims?
A. HIPAA-AS does not set any rules for paper claims. You can continue
to send them as you do today.
Q. Will claims continue to be paid as they are today?
A. The rules of HIPAA-AS do not change how a payer compensates providers
for health care services. There should be no change to an operation's
cash flow.
Q. Will I be able to send the exact same claim data
to every payer?
A. While the goal of HIPAA-AS is to standardize electronic transactions,
there will still be some differences from payer to payer.
Testing and Implementing Transactions
Q. What types of testing are offered?
A. See Wellmark's Testing Toolkit with information on how to test.
Wellmark
offers testing through the INet's Model Office system, which will provide
front-end
testing
of the
acceptance
process
for an
electronic transaction. This testing option is available to
all submitters and vendors. Wellmark also offers full system testing,
including claim adjudication and electronic remittance advice, for
key
submitters.
Health claims - 837 Institutional, 837 Professional, and 837 Dental
Testing for the claims transaction (ANSI 837) is available through
INet.
This service provides the opportunity for you to check your test file
against the ANSI 837 format and receive the reports produced from this
test.
For instructions on sending the test claims file, see the INet Account
Library article titled ANSI 837 Testing Instructions. Information
regarding testing for other transactions will be provided as available.
Q. Do direct submitters/clients need to test if
their vendors have tested with Wellmark?
A. Yes. Although your vendor will provide the ability for you
to create the standard format, the transaction is not complete without
your data. Testing by your vendor would be helpful. However,
a test sent from your system with your test data is preferred.
Q. How many test claims are needed?
A. Wellmark suggests that testing of software include sufficient claims
to fully test a system. This would include sample claims for each type
of business supported by health care practitioners and facilities.
Q. Do we need a separate ID and password for testing
purposes? If so, what would they be?
A. Separate ID numbers and passwords will be used for testing. Documentation
for testing procedures will indicate user IDs, passwords, dial-up procedures
and reporting expectations for the HIPAA-AS Transaction testing. Instructions
for testing transactions can be found in INet Account Library article
1ANSI837.pdf, or you can call EC Solutions at 515.248.5246 or 800.407.0267.
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