HIPAA Transactions and Code Sets:
The HIPAA transactions and code set standards are rules that
standardize the electronic exchange of health-related administrative
information, such as claims forms. The
rules are based on electronic data interchange (EDI) standards, which allow for
the exchange of information from computer-to-computer without human
involvement.
A "transaction" is an electronic business document. Under HIPAA, a handful of standardized
transactions will replace hundreds of proprietary, non-standard transactions
currently in use. For example, the HCFA 1500 claims form/file will be replaced
by the X12 837 claim/encounter transaction. Each of the HIPAA standard transactions has a
name, a number, and a business or administrative use. Those of importance in a medical practice
are listed in the table below.
|
Name of transaction
|
Number
|
Business use
|
|
Claim/encounter
|
X12 837
|
For submitting claim to health plan, insurer, or other
payer
|
|
Eligibility inquiry and response
|
X12 270 and 271
|
For inquiring of a health plan the status of a patient.s
eligibility for benefits and details regarding the types of services covered,
and for receiving information in response from the health plan or payer.
|
|
Claim status inquiry and response
|
X12 276 and 277
|
For inquiring about and monitoring outstanding claims
(where is the claim? Why haven.t you
paid us?) and for receiving information in response
from the health plan or payer. Claims
status codes are now standardized for all payers.
|
|
Referrals and prior authorizations
|
X12 278
|
For obtaining referrals and authorizations accurately and
quickly, and for receiving prior authorization responses from the payer or
utilization management organization (UMO) used by a payer.
|
|
Health care payment and remittance advice
|
X12 835
|
For replacing paper EOB/EOPs and explaining all adjustment
data from payers. Also, permits
auto-posting of payments to accounts receivable system.
|
|
Health claims attachments (proposed)
|
X12 275
|
For sending detailed clinical information in support of
claims, in response to payment denials, and other similar uses.
|
|
