The HIPAA/EDI provision was scheduled to take effect October 16, 2003 with a one-year extension for certain "small plans"; however, due to widespread confusion and difficulty in implementing the rule, CMS granted a one-year extension to all parties. As of October 16, 2004, full implementation was not achieved and CMS began an open-ended "contingency period." Penalties for non-compliance were not levied; however, all parties are expected to make a "good-faith effort" to come into compliance.

CMS has announced that the Medicare contingency period will end July 1, 2005. After July 1, most medical providers that file electronically will have to file their electronic claims using the HIPAA standards in order to be paid. There are exceptions for doctors that meet certain criteria.

Key EDI transactions are:

1) 837: Medical claims with subtypes for Professional, Institutional, and Dental varieties.

2) 820: Payroll Deducted and Other Group Premium Payment for Insurance Products

3) 834: Benefits enrollment and maintenance

4) 835: Electronic remittances

5) 270/271: Eligibility inquiry and response

6) 276/277: Claim status inquiry and response

7) 278: Health Services Review request and reply

These standards are X12 compliant, and are grouped under the label X12N.

Implementation Guides are available for free from the Washington Publishing Company.