HIPAA transaction standards

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HIPAA adopted certain standard transactions for Electronic Data Interchange (EDI) of health care data.

These transactions are:

  • claims and encounter information,
  • payment and remittance advice,
  • claims status,
  • eligibility, enrollment and disenrollment,
  • referrals and authorizations, and
  • premium payment.

Under HIPAA, if a covered entity conducts one of the adopted transactions electronically, they must use the adopted standard. This means that they must adhere to the content and format requirements of each standard.

HIPAA also adopted specific code sets for diagnosis and procedures to be used in all transactions. The HCPCS (Ancillary Services/Procedures), CPT-4 (Physicians Procedures), CDT (Dental Terminology), ICD-9 (Diagnosis and hospital inpatient Procedures), ICD-10 (As of October 1, 2013) and NDC (National Drug Codes) codes with which providers and health plan are familiar, are the adopted code sets for procedures, diagnoses, and drugs.

Finally, HIPAA adopted standards for unique identifiers for employers and providers, which must also be used in all transactions, as required by the standard.

Guidance

HHS page on HIPAA transaction standards

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