1.0 Purpose
The purpose of this chapter
is to ensure compliance with the Health Insurance Portability and Accountability
Act (HIPAA) of 1996, including the Administrative Simplification
provisions, by TRICARE contractors.
2.0 Background
2.1 HIPAA
The HIPAA of 1996 was introduced
as the Kassebaum/Kennedy Bill and was enacted on August 21, 1996,
as Public Law 104-191. Public Law 104-191 is, “An Act to amend the
Internal Revenue Code of 1986 to improve portability and continuity
of health insurance coverage in the group and individual markets,
to combat waste, fraud, and abuse in health insurance and health
care delivery, to promote the use of medical savings accounts, to
improve access to long-term care services and coverage, to simplify
the administration of health insurance, and for other purposes.”
2.2 Administrative Simplification
Through subtitle F of Title
II of the Act, Congress added to Title XI of the Social Security
Act a new Part C entitled, “Administrative Simplification.” The
purpose of this part is to improve the Medicare and Medicaid programs
under titles XVIII and XIX of the Social Security Act respectively
and improve the efficiency and effectiveness of the health care
system in general by encouraging the development of a health information
system through the establishment of standards and requirements to
enable the electronic exchange of certain health information.
2.3 Other Provisions
The law requires the Secretary,
Health and Human Services (HHS) to adopt standards for financial
and administrative transactions, and data elements for those transactions,
to enable health information to be exchanged electronically. It
requires the Secretary, HHS to adopt standards for unique health
identifiers for all individuals, employers, health plans, and health
care providers and to adopt standards for security for health care
information systems and for electronic signatures. Congress also
instructed the Secretary, HHS to promulgate privacy standards for
the protection of Individually Identifiable Health Information (IIHI)
should Congress fail to do so. The law establishes civil monetary penalties
for violations of the provisions of Part C and establishes penalties
for a knowing misuse of unique health identifiers and IIHI.
2.4 TRICARE Operations Manual (TOM)
This chapter incorporates,
where required, instructions for each HIPAA-related final rule as
they are published by the Department of Health and Human Services
(DHHS).