Adopted Standards and Operating Rules
HIPAA required HHS to establish national standards for electronic transactions to improve the efficiency and effectiveness of the nation's health care system.
These standards apply to all HIPAA-covered entities:
- Health plans
- Health care clearinghouses
- Health care providers who conduct electronic transactions, not just those who accept Medicare or Medicaid
Any provider who accepts payment from any health plan or other insurance company must comply with HIPAA if they conduct the adopted transactions electronically.
These providers must also have written agreements in place to ensure business associates comply with HIPAA. Examples of business associates include clearinghouses and independent medical transcriptionists.
Below is an overview of all the adopted standards for electronic health care transactions as of June 2016.
Standards
ASC X12 Version 5010 is the adopted standard format for transactions, except those with retail pharmacies.
For retail pharmacy transactions, HHS adopted two standards from the National Council for Prescription Drug Programs (NCPDP):
- Pharmacy and supplier transactions – NCPDP Version D.0
- Medicaid subrogation – NCPDP Version 3.0
Summaries of adopted standards and operating rules for transactions and code sets follow.
Adopted Transaction Standards and Operating Rules
| Transaction |
Standard |
Federally Mandated Operating Rules |
Compliance Date |
|---|---|---|---|
| Health claims (institutional, professional, and dental) |
ASC X12N 837 Version 5010 |
No |
Standard: Jan 1, 2012 |
| Eligibility and benefit verification |
ASC X12N 270/271 Version 5010 |
Yes |
Standard: Jan 1, 2012 Operating rules: Jan 1, 2013 |
| Prior authorization and referrals |
ASC X12N 278 Version 5010 |
|
Standard: Jan 1, 2012 |
| Claim status inquiry and response |
ASC X12N 276/277 Version 5010 |
Yes |
Standard: Jan 1, 2012 Operating rules: Jan 1, 2013 |
| Claim payment (or EFT, electronic funds transfer) |
ACH CCD+Addenda ASC X12N 835 Version 5010 |
Yes |
ACH standard: Jan 1, 2014 Version 5010 standard: Jan 1, 2012 Operating rules: Jan 1, 2014 |
| Electronic remittance advice (ERA) |
TRN Associated Trace Number ASC X12N 835 Version 5010 |
Yes |
TRN standard: Jan 1, 2014 Version 5010 standard: Jan 1, 2012 Operating rules: Jan 1, 2014 |
| Coordination of benefits |
ASC X12N 837 Version 5010 |
No |
Standard: Jan 1, 2012 |
| Referral certification |
ASC X12N 278 Version 5010 |
No |
Standard: Jan 1, 2012 |
| Retail pharmacy drug claim submission |
NCPDP D.0 |
No |
Standard: Jan 1, 2012 |
| Medicaid pharmacy subrogation |
NCPDP 3.0 |
No |
Standard: Jan 1, 2012 |
|
Enrollment/disenrollment in a health plan |
ASC X12N 834 Version 5010 |
No |
Standard: Jan 1, 2012 |
| Premium payment/ explanation (employer) |
ASC X12N 820 Version 5010
|
No |
Standard: Jan 1, 2012 |
Adopted Standard Code Sets
| Activity |
Standard |
| Diagnosis coding |
ICD-10-CM—International Classification of Diseases, 10th edition, Clinical Modification |
| Hospital inpatient procedure coding |
ICD-10-PCS—International Classification of Diseases, 10th edition, Procedure Coding System |
| Outpatient procedure and physician services coding |
CPT—Current Procedural Terminology |
| Supplies/not included in CPT |
HCPCS—Healthcare Common Procedure Coding System |
| Dental procedure coding |
CDT—Code on Dental Procedures and Nomenclature |