Under HIPAA, HHS adopted standards for electronic transactions, including for health care claim status.
A health care claim status transaction is used for:
- An inquiry from a provider to a health plan to determine the status of a health care claim
- A response from the health plan to a provider about the status of a health care claim
In January 2009, HHS adopted Version 5010 of the ASC X12N 276/277 for health care claim status. For more information, see the official ASC X12N website.
This standard applies to all HIPAA-covered entities, health plans, health care clearinghouses, and certain health care providers, not just those who work with Medicare or Medicaid.
As of January 1, 2013, HIPAA-covered entities are required to comply with federally mandated operating rules for eligibility and claims status.
The operating rules streamline the way eligibility/benefits and claim status information is exchanged electronically. For example, health plans must furnish real-time online access to claims status information, making it easier for providers to determine the status of a claim submitted to a health plan.
View the health care claim status operating rules on the CAQH CORE website