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Transactions are electronics exchanges involving the transfer of health care information between two parties for specific purposes, such as a health care provider submitting medical claims to a health plan for payment. The Health Insurance Portability & Accountability Act of 1996 (HIPAA) named certain types of organizations as covered entities, including health plans, health care clearinghouses, and certain health care providers. HIPAA also adopted certain standard transactions for Electronic Data Interchange (EDI) for the transmission of health care data. These transactions are: claims and encounter information, payment and remittance advice, and claims status, eligibility, enrollment and disenrollment, referrals and authorizations, and premium payment. Under HIPAA, if a covered entity conducts one of the adopted transactions, they must comply with the adopted standard. This means that they must adhere to the content and format requirements that are specified in the HIPAA standards. HIPAA also requires every covered entity to use certain codes to identify specific diagnosis and clinical procedures on claims, encounter forms and other 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 are familiar, are examples of code sets for procedures, diagnoses, and drugs. Finally, HIPAA adopted standards for unique identifiers for Employers and Providers. Information about the identifiers can be found in the "Related Links Inside CMS" section below. HIPAA Information Series for Providers- A series of ten papers devoted to electronic transactions and code sets. To view these papers, see the "Related Links Inside CMS" section below.
Page Last Modified: 04/06/2009 4:47:24 PM
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