HIPAA Transactions

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HIPAA Standards for Electronic Healthcare Transactions

HIPAA required the Department of Health and Human Services (HHS) to adopt national standards for electronic healthcare transactions. All covered entities must comply with the electronic transactions and code sets standards adopted by HHS.

Covered entities under HIPAA include:

  • Health plans
  • Healthcare providers who transmit health information in electronic form in connection with a transaction covered by HIPAA
  • Healthcare clearinghouses

The electronic healthcare transactions covered under HIPAA that may affect provider organizations include:

Transaction Description HIPAA Transaction Standard Molina Readiness Status
Claims or Encounter Information ASC X12N 837 Professional, or Institutional Healthcare Claims and Encounters Implemented
Eligibility for a Health Plan ASC X12N 270/271 Healthcare Eligibility Benefit Inquiry and Response Implemented
Referral Certification and Authorization ASC X12N 278 Healthcare Services Review - Request for Review and Response Implemented
Claims Status ASC X12N 276/277 Healthcare Claim Status Request and Response Implemented
Payment and Remittance Advice ASC X12N 835 Healthcare Claim Payment/Advice Implemented

IMPORTANT NOTE:

HIPAA does not require healthcare providers to conduct the above transactions electronically with Molina Healthcare. For example, if you currently submit claims to Molina Healthcare using paper, you may continue to do so.

Affordable Care Act

The Patient Protection and Affordable Care Act - HR 3590, also called the “Affordable Care Act” was enacted on March 23, 2010. The Affordable Care Act (ACA) includes provisions related to administrative simplification (Sec. 1104) and standards for financial and administrative transactions (Sec. 10109). It calls for the National Committee on Vital and Health Statistics (NCVHS) to provide input into the process of rulemaking for the establishment of a unique health plan identifier and to provide advice and recommendations to the Department of Health and Human Services (HHS) relative to Operating Rules for electronic exchange of information not defined by a standard or its implementation specification. Operating Rules development shall be conducted by a qualified nonprofit entity that meets specific requirements.

Pursuant to ACA, the Secretary of HHS has adopted the below Operating Rules:

Adoption of operating rules Effective Date Molina Readiness Status
Eligibility for a health plan and health claim status January 1, 2013 Implemented
Electronic funds transfers and health care payment and remittance advice January 1, 2014 Implemented
Health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, and referral certification and authorization TBD Awaiting Final Rule

How to get started exchanging HIPAA transactions with Molina Healthcare

Review Molina's EDI Website and follow the steps indicated.

HIPAA Implementation Guides

HIPAA ANSI X12 Transaction Standards can be downloaded from the www.wpc-edi.com website.
Molina Healthcare Electronic Data Interchange (EDI) Materials and Companion Guides.

Contact the HIPAA Help Team:

  • HIPAA Transactions testing and enrollment
    Contact Molina's EDI Team.

If you are a provider and have a concern or complaint regarding Molina’s HIPAA Transaction Code Sets compliance or any other HIPAA issue call our HIPAA Provider Hotline toll free at 1-866-MOLINA2 (1-866-665-4622) or email us at HIPAAMailbox@MolinaHealthcare.com.

  • General HIPAA Questions or Comments:

Contact Molina's HIPAA Program Office as listed in the Contact HIPAA section below:

For general business questions: Please contact your Molina Healthcare provider services representative.

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