Providers

Client Data Collection and Reporting

HIPAA and Electronic Billing

The Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) is having a huge impact on health care systems. Among many other features, it sets standards for the electronic transmission of health care data. As of October 16, 2003, any health care service provider has the option of sending client medical billing data electronically to a health plan (or payer), but if they do, the data must be in a HIPAA compliant format. That health plan in turn must be able to receive and process the data and respond electronically, likewise in a HIPAA compliant format.

The Department of Human Services is considered a health plan because we and our partner contractual agencies implement the State's Home and Community Based Waiver program (CIP / COP / Waiver funding) and the Interim Assistance (IA) program. Through them we pay for medical services for the disabled, elderly and those unable to work. Therefore, as of October 16, any organization (professional, institutional, dental or pharmacy) that provides a medical service for a CIP / COP / Waiver or IA client can choose to submit their medical claims to us electronically. Should they choose to do so, they must first sign a Trading Partner Agreement (fillable PDF file) with us, complete a Trading Partner Profile (fillable PDF file), and submit a test batch of claims to us. Here are additional Profile instructions (also a PDF file). One caveat, if the Trading Partner is billing through a third party (such as a clearinghouse or billing service), they don't have to submit a Trading Partner Profile, but the Third Party does. In that case the Trading Partner should identify them in the Trading Partner Agreement and the Department will contact them directly.

Only claims for medical services or products for the CIP / COP / Waiver or IA programs will be accepted and processed electronically. These include and (at most) are limited to the following services or products, although individual program restrictions may further reduce this list:

Health Care Service or Product Eligible for Electronic Billing

A list of the SPC Codes and their description that are eligible for electronic billing under HIPAA regulations.

Health Care Service or Product SPC Code
Adaptive Aids (Durable Medical Equipment and Disposable Medical Supplies) 112.99
Case Management 604
Counseling & Therapeutic Resources 507.03
Communications Aids (Durable Medical Equipment and Disposable Medical Supplies) 112.47
Community Support Program 509
Day Treatment – Medical 704
Disposable Medical Supplies 112.55
Skilled Nursing Services (Independent/Private Duty Nursing) 710

For further information, please see the Wisconsin Dept. of Health and Family Services HIPAA web site at www.dhfs.state.wi.us/HIPAA/, or contact Kari Clemens at 608-242-6298.

04/30/2014