How will HIPAA impact Medi-Cal providers?

Simplifying Electronic Claims

Transmitting health care claims and other health care transactions electronically in the national standardized format will streamline billing processes. Electronic data exchange reduces the administrative burden, lowers operating costs and improves overall data quality. When providers switch to electronic claims, the handling and processing time involved with paper documents is reduced. In addition, changing over to the national standard format will inimize expenses associated with developing and maintaining software. When all systems are completed, the data sent to Medi-Cal will be in the same electronic format as other health care plans, thus making training new staff easier.

Computer Media Claims

Providers who elect to submit Computer Media Claims (CMC) on tape, diskette or by electronic telecommunications will be required to conform to the new ANSI ASC X12 837, Version 4010, format. The electronic, proprietary Medi-Cal format and the National Standard Format (NSF) Version 4 Flat File will be phased out.

Pharmacy Claims

Providers who elect to submit electronic retail pharmacy claims will be required to conform to the National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Version 5.1 and equivalent NCPDP Batch Standard 1.0 formats. Electronic claims generated by a Pharmacy Practice Management System (PPMS) must also be sent in the NCPDP Telecommunication Standard Version 5.1 format. The existing CMC batch process will be upgraded to the HIPAA compliant NCPDP Batch Standard 1.0 format. In addition, a new Internet application will be implemented by Medi-Cal for online real-time submission of electronic pharmacy claims in the NCPDP Version 5.1 format.

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HIPAA References
Department of Health and Human Services Administrative Simplification Web site
Centers for Medicare & Medicaid Services
Medi-Cal HIPAA Update

Implementation Guide
National Council for Prescription Drug Programs (NCPDP)