Standards for Transactions
Under HIPAA, HHS adopted certain standard transactions for the electronic exchange of health care data. These transactions include:
- Payment and remittance advice
- Claims status
- Coordination of benefits
- Claims and encounter information
- Enrollment and disenrollment
- Referrals and authorizations
- Premium payment
Learn more about transactions with the following fact sheets:
Additional Provisions to Simplify the Business of Health Care
In 2010, subsequent legislation introduced additional provisions that addressed the use of transactions, building upon the requirements already in place through HIPAA. Together, the provisions are referred to as Administrative Simplification, because their purpose is to simplify the business of health care.
The new and expanded provisions included requirements for the adoption of:
- Operating rules for each of the existing transactions
- A standard unique identifier for health plans
- Standards for electronic funds transfer and electronic health care claims attachments
These provisions also created a new requirement for health plans to certify their compliance with the adopted standards and operating rules. They also established a new set of penalties that could be imposed on health plans for failure to comply or to certify their compliance.
Enforcement of the Administrative Simplification provisions under HIPAA and subsequent legislation falls under HHS and is carried out by the National Standards Group (NSG) at CMS. Information about enforcement, compliance, and complaints can be found in the section of this website.
Keep Up to Date!
Eligibility and Benefits Transaction (PDF)