Questions & Answers About HIPAA Transaction And Code Sets Standards

How does HIPAA affect provider reimbursement contracts?

All electronic claim submissions must now contain HIPAA compliant medical and non-medical code sets. Therefore, contracts may need to be modified in order to reflect a valid alignment of contracted procedures and corresponding reimbursement rates.

How does HIPAA affect fee schedules?

To support HIPAA compliance, Cigna HealthCare will add the HIPAA-compliant codes to the fee schedules.

How are your web-sites impacted by the transaction and code sets regulations?

The HIPAA Transactions & Code Sets regulations do not affect, and our CIBUR site.

What changes did Cigna HealthCare make to Provider Self-Service (PSS)?

In July 2003, PSS was changed to support eligibility and benefit inquiries and response (270/271), as well as claim status inquiries and response (276/277).

Here are some of the changes you'll notice:

Claim Status:

  • The status field now shows whether the claim is pending or in process.
  • Explanation of Payment Remark codes, now called "Additional Information," are now HIPAA-compliant. These codes are used only for electronic transactions (PSS). On a single inquiry you are now able to inquire about services provided within a 180-day date range.

Eligibility and Benefits:

  • Product Type
  • The screen now shows additional information when applicable:
  • Medical Group/Risk Group Name
  • PCP phone number
  • Outpatient hospital out-of-pocket expense
  • MRI/Lab/X-ray copayments
  • The coinsurance percentage Cigna HealthCare applies to a covered expense (instead of the percentage the member must pay).
What is Provider Self-Service?

With this "application," or tool, you can check your patient's benefits, eligibility or claim information conveniently and securely online. Access is available during the following hours:
Monday through Friday, 7 a.m. to Midnight ET
Saturday, 7 a.m. to 8 p.m. ET
Sunday*, 2 p.m. to 7 p.m. ET

With what vendors is Cigna HealthCare connected?

Click here for vendors connected with Cigna HealthCare.