HIPAA-AS Q&A for IT Vendors
Wellmark Transaction/Code Set Compliance
- 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
Format 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
- 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
The code sets specified by HIPAA-AS rules are:
Current Procedural Terminology (CPT-4)
ICD-9-CM, Volumes 1 & 2
Other health problems
ICD-9-CM, Volume 3
Current Dental Terminology (CDT-4)
HCPCS - Level 2
Physical Occupational Therapy
Other Medical Diagnostics Procedures
Hearing and Vision
Durable Medical Equipment
Testing and Implementing Transactions
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.