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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 NCPDP, the National Council for Prescription Drug Programs:

  • 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

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