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Provider Manual

Trading partner for electronic data interchanges

Last Updated on August 28, 2018

Security Health Plan is unable to accept electronic transmissions of claims or other transactions set forth in the HIPAA Transactions/Code Sets regulations other than in the standardized format required by those regulations. If the affiliated provider transmits the transactions electronically to Security Health Plan, he or she will need to transmit them in the standardized format or use a clearinghouse to do so.

The Trading Partner for Electronic Data Interchange section sets forth the terms governing the transmissions of such electronic transactions by Security Health Plan and affiliated providers who will be considered trading partners for purposes of these transactions.

 Below is a list of Clearinghouses which transmit directly to SHP

  • Claim Lynx, Inc.
  • Cvikota Company Inc.
  • Emdeon (Change Healthcare)
  • Gateway/TriZetto
  • Health Care Data Systems
  • MCPS
  • Navitus
  • Optum Insight
  • OutSource Inc.
  • Quadax
  • Rycan Technologies Inc.
  • Smart Data Solutions
  • SSI Group
  • Zelis Healthcare
  • ZirMed

Definitions

Terms not otherwise defined in this section shall have the meanings given to them in Title 45, Parts 160, 162 and 164 of the CFR (“HIPAA”) and are incorporated herein by reference. In addition, the following capitalized terms shall have the following meanings:

  • “DHHS” means the Department of Health and Human Services or its designated representative.
  • “Implementation guide” means the industry guide for a Standard Transaction adopted for use under HIPAA and setting forth required formats, data elements, code sets and all other implementation specifications.
  • “Information” means electronic information transmitted, provided or otherwise exchanged between Security Health Plan and the affiliated provider.
  • “Standard transaction” means an electronic transmission governed by the Transaction Rule.
  • “Trading partner” means an entity that transmits information to or receives information from another entity electronically.
  • “Transaction rule” means HIPAA’s transaction standard regulation as set forth at 42 CFR §§ 160 and 162 and as amended.

Prerequisites

Documents: Standards and Guidelines

Security Health Plan and the affiliated provider may electronically transmit to or receive from each other any of the standard transactions (collectively “documents”). All documents shall be transmitted and processed in accordance with those standards and guidelines specified in the implementation guides. Notwithstanding the foregoing, neither Security Health Plan nor the affiliated provider shall (and this section shall not, in any way, be deemed or construed to):

  • change any standard transaction definition, data condition or use of a data element or segment
  • add any data elements or segments to the maximum defined data set
  • use any code sets or data elements that are marked “not used” or do not appear in the implementation guide, or
  • change the meaning or intent of any of the DHHS transaction standard’s implementation specifications.

Direct or service provider alternatives

Either Security Health Plan or the affiliated provider may transmit documents to each other directly or through a third party provider designated by the transmitting party (“provider”). Either Security Health Plan or the affiliated provider may designate additional providers upon written notice to the other party.

Systems operation

Security Health Plan and the affiliated provider are responsible for ensuring that it or its providers can effectively and reliably transmit and receive documents and shall be liable for the acts or omissions of its providers while transmitting, receiving, storing or handling standard transactions, or performing related activities. If Security Health Plan and the affiliated provider use the same provider to effect the transmission and receipt of a standard transaction, the originating party shall be liable for the acts or omissions of the provider as to such standard transaction.

Allocation of costs

Security Health Plan and the affiliated provider shall be responsible for the payment of its own fees and other charges incurred or assessed by it in transmitting or receiving documents, including, without limitation, those fees charged by any of its providers.

Test modification

If Security Health Plan or the affiliated provider (the “requesting party”) applies to DHHS and obtains, for testing purposes, an exception from the use of a standard transaction, the requesting party shall provide the other party 30 days’ prior written notice of such exception. Effective at the end of such 30-day period, the other shall modify its transmission and/or receipt of documents to comply with the granted DHHS exception. If this occurs, trading partner agrees that it will participate in such test modifications.