Transactions are electronic exchanges involving the transfer of information between two parties for specific purposes.  For example, a health care provider will send a claim to a health plan to request payment for medical services.  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) 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.  Information about the identifiers can be found in the "Related Links Inside CMS" section below.  

NEWS:  On October 16, 2009, CMS published a Request for Information (RFI) regarding Monitoring Compliance with the Transactions and Code Sets, National Identifier and Unique Employer Identifier Rules.  This RFI is intended to collect industry feedback on specific topics that will assist CMS with refining future strategies for the HIPAA enforcement process.  The response date is December 1, 2009.   For more details and to view the solicitation, please see the "Related Links Outside 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.

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Related Links Inside CMS
HIPAA Information Series for Providers HIPAA - General Information HCPCS Release and Code Sets Employer Identifier Standard National Provider Identifier
Related Links Outside CMS
CMS Published Enforcement RFI

Page Last Modified: 11/19/2009 10:58:50 AM
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