Healthcare Providers and HIPAA Compliance

DCS EDI Consultants Ensure Success

HIPAA EDI (Health Insurance Portability and Accountability Act) is too often erroneously considered a technical hurdle. Instead, it should be considered an opportunity to polish your data processes. Your successful upgrade will provide small improvements in process automation to speed payment, enable your staff to focus upon other challenges, and cap head count. We can help you integrate with other organizations using your existing practice management system. And, we can help you incrementally so you can manage your budget.

Our approach is based upon self-reliance: we help you move to version 005010.  Doing it yourself, working with an expert to show you how and answer your questions, is also the most economical.  Here are the key steps:

  1. Gap analysis – We do this jointly.  It takes about 60 hours.
  2. Map configuration (004010 to 005010) and system testing – You do this task.
  3. Customized map for each payor or clearing house – You do this task (DCS is copied on all tests sent.)
  4. Facilitator gets clear and accurate responses to the tests using deft pressure – DCS does this task.  The time needed is about 4 hours per payor or clearing house.
  5. Documentation as ordered by you – DCS does this task.  It takes about 32 hours.
  6. Reporting to management – You do this task.

Total Time Budget – about 92 hours, plus about 4 hours per payor or clearing house.

The HIPAA Challenge

A large part of the HIPAA challenge is providing secure, reliable, accurate, and economical document exchange with payors and agencies. Integration is a significant task. EDI X12N structures are complex and difficult to tackle. For example, user exits and scripts are frequently used.

Document exchange is a significant portion of the HIPAA challenge and a highly technical activity. Implementing the appropriate EDI and AS2 applications for your organization is a key to HIPAA compliance. Once application installation has occurred, solid development and testing practices must be followed to ensure successful, prompt, and accurate translation of the medical claims.  You know your organization’s unique business practices; we know the technical changes required.

The X12N version 005010 replaces 4010A1 and has been mandated to be fully compliant (Level I and Level II) by January 1, 2012. The 005010 version will be effect for several years, so consider streamlining your claims and remittance processing. You will decrease your business office processing time through better integration with Coordination of Benefits (COB), remittance, and paper claims such as the UB92 form. We can assist in implementing ICD-10 codes, Subscriber/Patient hierarchy changes, and claim balancing too.

Typically, the first step in a version upgrade is gap analysis (about 60 hours of effort).  This provides a solid foundation upon which your plan is based.  The gap analysis is critical to discover what back-end systems must be updated to capture the appropriate data. For example, clinical modifications of the ICD10-CM may require detailed data entry in early patient management screens where the window of opportunity is narrow. Changes to the Procedure Coding Structure (ICD10-PCS) allow procedure codes to now be linked directly to diseases and disorders. “Not otherwise specified” catch-all generic procedure codes will be restricted forcing greater data capture by your EDI system. These are critical paths that must be sought out and analyzed before mapping changes can occur. Let DCS EDI consultants provide you with a detailed report of updates needed.

For an in-depth technical review click here.


Our sound methodologies ensure the implementation occurs smoothly. The components (EDI and AS2) can be orchestrated more harmoniously with expertise at hand. Since providers need to be self-reliant and cost conscious, doing EDI with an expert that wants to help you improve your skills makes sense.

Since improvement is not trivial, we recommend DCS development service. DCS’ many years experience in EDI across the nation is the foundation for DCS GROW™ development service. Our decades of experience can help you find the solutions that are most appropriate in your situation and how to apply them quickly.

From integration, to remote support, to user training; DCS offers the array of support needed for a solution to the HIPAA challenge. Using a seasoned expert who knows EDI and AS2 will save you time and headaches. Your first step is easy, email DCS for your no-cost assessment.