HIPAA Transaction FAQs

Are small provider practices exempt from the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Transactions and Code Sets regulations?

No. Regardless of practice size, all providers transmitting designated transactions electronically are subject to the HIPAA Administrative Simplification requirements. Effective October 16, 2003, small practices are exempt from the Administrative Simplification Certificate Act (ASCA) provision that excludes paper claims from Medicare coverage. Small practices will be able to continue to submit paper claims. ASCA defines a small practice or supplier as:

  1. A provider of services with fewer than 25 full-time equivalent employees or
  2. A physician, practitioner, facility or supplier (other than provider of services) with fewer than 10 full-time equivalent employees.
What is the process for obtaining the “production green light” for submitting ANSI X-12 transactions?

Blue Cross has developed a Partner Testing approach to ensure Trading Partner transactions are ANSWER HIPAA compliant and meet Blue Cross business rules. The extensive testing required during the  Partner Testing phase should result in a smooth transition to production. In general, the major components are:

  • Complete the Trading Partner Agreement and Trading Partner Registration form.
  • Successfully test files using the Foresight Online Validator tool.
  • Successfully test files through the Blue Cross end-to-end test environment (Phase 2).

For additional information on HIPAA Partner Testing contact the Blue Cross Service Desk at (401) 751-1673 or 1-855-721-4211or hipaa.edi.support@bcbsri.org. An EDI analyst will work with you during each phase of partner testing.


Where can I get a copy of the Blue Cross Companion Guides for submitting/receiving ANSI X12 transactions?

You can obtain copies of our Companion Guides on the HIPAA Transactions Documents page.

The Institutional and Professional Implementation Guides do not specifically address what format to use when submitting home infusion claims. How will Blue Cross process a home infusion claim submitted as an 837 Institutional claim? How will Blue Cross process a home infusion claim submitted as an 837 Professional claim?

Blue Cross EDI Gateway must accept any ANSI-compliant home infusion claim submitted on either 837I or 837P. However, Blue Cross will reject any 837P home infusion claim during the internal business editing process as “not a contracted service for this form type.” A home infusion provider would have to use the 837I format in order to receive payment under the terms of their contract.

I’m a provider who is using a valid CPT code for something other than for what it is defined. There is no available code that accurately identifies the program and reimbursement arrangement Blue Cross has with providers. If I continue to use this code in that way, would this be in violation of HIPAA compliance?

In situations where there is no clear national code set equivalent, the closest valid national code set will be selected and used to process applicable claims.

How is an 837 claim that has more than 28 lines handled within Blue Cross?

We accept the HIPAA limits—50 lines for Professional claims and 98 lines for Institutional claims. If a professional claim has more than 50 lines, it is rejected up front and will appear on your Provider Control Report. If we receive an institutional claim with more than 98 lines, the claim is split manually.

Should there always be a 999 Acknowledgement for each 837 file submitted?

You should always expect a 999 Acknowledgement and Plain Language 999 for each 837 file you submit. If a reasonable time has elapsed since file submission and you have yet to receive the appropriate 999, please contact Blue Cross Service Desk at 401-751-1673 or 1-855-721-4211 for assistance.

Will providers continue to receive the current paper remittance advice (RA)?

Yes, for those providers who are not enrolled in Direct Deposit, the current paper remittance advice will be produced.

After getting the “go ahead” for submitting ANSI X-12 claims in production, will there be changes I need to make? If so, what are those changes?

Yes. You will need to change the first position of the Submitter ID from “T” (Test) to “P” (Production). You will also need to change the ISA15 from “T” (Test) to “P” (Production).

I have “Provider Control Reports” in my mailbox. What is the purpose of these reports?

The Provider Control Reports identify claims that were not accepted for claims adjudication. This reject report will list any claim that is rejected from our front-end edit process and the reason the claim rejected. These claims must be corrected by you and resubmitted for processing.

What is the difference between a Type 1 and Type 2 NPI?

Type 1 NPIs are healthcare providers, such as physicians and dentists. Type 2 NPIs are organizations such as facilities, hospitals, home health agencies, labs, and DME suppliers.