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Health Care Claims Status

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

HIPAA Adopted Standards

In January 2009, HHS adopted Version 5010 of the ASC X12N 276/277 for health care claim status.

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.

Operating Rules

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 Phase I Operating Rules and Phase II Operating Rules for health care claim status on the CAQH CORE website. 

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