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Referral Certification and Authorization

Under HIPAA, HHS adopted standards for electronic transactions, including for referral certification and authorization.

The referral certification and authorization transaction is any of the following:

  • A request from a health care provider to a health plan to obtain an authorization of health care
  • A request from a health care provider to a health plan to obtain authorization for referring an individual to another health care provider
  • A response from a health plan to a health care provider about authorization and referral requests

HIPAA Adopted Standards

In January 2009, HHS adopted Version 5010 of the ASC X12N 278 for referral certification and authorization.

For pharmacy-related referral certifications and authorizations, HHS adopted NCPDP Telecommunications Standard Version D.0. 

These standards apply to all HIPAA-covered entities, health plans, health care clearinghouses, and certain health care providers, not just those who work with Medicare or Medicaid.

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