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Current Initiatives

Health and Human Services (HHS)/ Centers for Medicare and Medicaid Services (CMS) HIPAA Transactions Compliance Review Program (CRP)

Late March 2019, CMS on behalf of HHS, announced their plans to launch a CRP to ensure HIPAA covered entities comply with HIPAA named and adopted electronic healthcare administrative transaction standards. Starting in April 2019, HHS will randomly select a mix of 9 HIPAA covered entity health plans and clearinghouses every year –– for compliance reviews. When selected for compliance review, TRICARE as a Health Plan will have 30 days to complete a HIPAA transactions compliance review and provide results to CMS.

DHA's HIPAA TCS&I office received CMS' initial announcement about the CRP and communicated with key DHA stakeholders toward rapidly executing a CRP when the time comes. For more information, please email the HIPAA TCS&I Office.

New By-Law Rule Requires Reporting of Quantity Prescribed for Schedule-II Drugs in Pharmacy HIPAA Electronic Transactions by 21 September 2020

On 24 January, 2020, the Department of Health and Human Services (HHS) posted Final Rule (FR) CMS-0055-F to the Federal Register. This HIPAA Final Rule (FR) modified requirements for use of the currently HIPAA named and adopted National Council on Prescription Drug Programs (NCPDP) Telecommunication Standard Implementation Guide Version D.0 by requiring the reporting of Quantity Prescribed (Data Element 460-ET) for Schedule II drugs (e.g., opioids). The required U.S. nationwide compliance date for this HIPAA FR was 21 September 2020. The FR can be found

The broad intent of the FR is for the U.S. healthcare industry to have and use the newly required data from Pharmacy HIPAA transactions to better track opioid prescriptions and to reduce the number of "fills" or “partial fills” that may end up being categorized as illicit “refills” for Schedule II drugs.

The DHA/J5/HIPAA Transactions, Code Sets, and Identifiers (HIPAA TCS&I) Office facilitated DHA’s related HIPAA compliance activities toward DHA Click to closeDirect CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”Direct Care (as a Provider entity) and Click to closePurchased CareThe TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.Purchased Care (as a Health Plan entity) achieving compliance with the FR requirements.

CAQH CORE Operating Rules

New Council on Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) CORE Operating Rules are expected to be recommended for HIPAA adoption at the National Committee on Vital and Health Statistics (NCVHS) Full Committee meeting scheduled for 18-19 November 2020. The proposed Operating Rules relate to Infrastructure, Data Content, and Security/Connectivity for HIPAA Referral/Authorization (X12 278) transactions as well as Security/Connectivity for HIPAA Eligibility (X12 270/271), Claim Status (X12 276/277), and Payment/Remittance Advice (X12 835) transactions.

The National Committee on Vital and Health Statistics (NCVHS) is soliciting U.S. health care industry feedback as part of its evaluation of the CAQH CORE request for HIPAA adoption of the proposed Operating Rules. DHA’s HIPAA TCS&I office communicated with key DHA stakeholders toward the opportunity to provide feedback to NCVHS.
For more information, please email the DHA HIPAA TCS&I Office.

MHS Efforts to Review Draft X12 Version 7030 Implementation Guides

X12 Incorporated (pronounced ex-12) is named in the Health Insurance Portability and Accountability Act (HIPAA) as a standards organization responsible for developing and maintaining electronic transaction standards for HIPAA-adopted healthcare administrative simplification (e.g., for eligibility, enrollment, referrals, claims, and claim payments). X12 is in the process of developing new versions of HIPAA transaction standards to replace the current HIPAA-adopted and implemented Version 5010. X12 has been working on Version 7030 for a number of years and Version 7030 was long thought to have been the next version to be named for adoption under HIPAA. However, X12 announced in 2020 that the completed Version 7030 implementation guides will form the basis of Version 8010, and X12 is expected to recommend to NCVHS that Version 8010 be named and adopted as the next HIPAA transaction standard.

X12 is still (currently, as of this writing) in the process of releasing draft versions of respective Version 7030 HIPAA transaction standards for review and comment by X12 members. Each respective Version 7030 standard has or is expected to have a designated period for the members to review and provide input. The Defense Health Agency (DHA) HIPAA Transactions, Code Sets & Identifiers (TCS&I) Office is the sole X12 voting member for the Military Health System (MHS); as such, the HIPAA TCS&I Office is facilitating the MHS review and feedback to X12 during each designated Version 7030 draft transaction standard review period. In order to facilitate X12’s consideration of MHS business process needs, the HIPAA TCS&I Office solicits input and coordinates with applicable MHS functional and technical stakeholders to support their specific needs related to the respective HIPAA transactions.

Process Phases

The HIPAA TCS&I Office-facilitated guide review process includes five phases (currently for comparing Version 7030 against implemented Version 5010).

  • Discovery Phase: Obtaining and pre-assessing the draft Version 7030 transaction guide and associated 7030 vs. 5010 change log.
  • Preparation Phase:  Combining the change log and other guide assessment findings into a structured change analysis tool for review by the HIPAA TCS&I Office and applicable MHS stakeholders.
  • Review Phase:  Analyzing the transaction changes, providing the structured change analysis tool to stakeholders, and facilitating live guide review sessions. Includes MHS stakeholder reviews.
  • Approve Phase:  Collecting, aggregating, and reviewing stakeholder feedback and escalating, as needed, through DHA leadership.
  • Finalize Phase:  Submitting consolidated MHS comments to X12 and coordinating with applicable MHS stakeholders, as needed, on any resulting responses from X12.

Timing and Duration of X12 Draft Version 7030 Transaction Implementation Guide Reviews 

View Draft Version 7030 Dashboard Status Metrics and Draft Version 7030 Review Timeline for change analysis updates.

Upcoming Transactions for Future Review:

  • Health Care Eligibility/Benefit Inquiry and Response (270/271): 1 November 2020 – 15 December 2020

Transactions Reviewed To Date:

  • Health Care Claim Request for Additional Information (277RFI): 1 October 2019 – 30 November 2019
  • Additional Information to Support a Health Care Claim or Encounter (275): 1 October 2019 – 30 November 2019
  • Additional Information to Support a Health Care Services Review (275): 1 October 2019 – 30 November 2019
  • Health Care Services Request for Review and Response (Prior-Authorizations/Referrals (278)): 1 September 2017 - 30 November 2017
  • Health Care Claim - Dental (837D):  1 February 2017 - 1 June 2017
  • Health Care Claim - Institutional (837I):  1 February 2017 - 1 June 2017
  • Health Care Claim - Professional (837P):  1 February 2017 - 1 June 2017
  • Health Care Claim Payment/Remittance Advice (835):  1 November 2016 - 30 January 2017
  • Health Care Claim Status Request and Response (276/277):  1 October 2016 - 30 November 2016
  • Benefit Enrollment and Maintenance (834):  1 September 2016 - 31 October 2016

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Last Updated: July 11, 2023
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