HIPAA 4010

Standards for transactions are rules under the Health Insurance Portability and Accountability Act (HIPAA) to standardize the electronic exchange of patient-identifiable health information via electronic data interchange (EDI) transactions for submitting, processing and paying claims. The Standards for Electronic Transactions and Code Sets, published August 17, 2000 and since modified, adopted standards for several transactions, including claims and encounter information, payment and remittance advice, and claims status.

HIPAA specifies transaction standards and code sets for added security of electronic protected health information (e-PHI). The Department of Health and Human Services (HHS) defines a transaction as an electronic exchange of information between two parties to carry out financial or administrative activities related to health care. For example, a health care provider will send a claim to a health plan to request payment for medical services.

These HIPAA standards apply to health plans, healthcare clearinghouses and health care providers that transmit healthcare information in electronic form to complete health care transactions. These national standards apply to electronic transmissions using all media, even when it is physically moved from one location to the next via magnetic tape, disk or CD.

These standards also apply to transmissions over the internet, private networks, leased lines, dial-up lines and other types of private networks. However, the standard does not pertain to telephone voice response or fax-back systems.

Under HIPAA, HHS adopted specific standard transactions for the electronic exchange of health care data. The following health care EDI transactions are covered by the standards:

  • Health care claims or similar encounter information
  • Health care payment and remittance advice
  • Coordination of benefits
  • Health claim status
  • Enrollment and disenrollment in a health plan
  • Eligibility benefit inquiry for a health plan
  • Health plan premium payments
  • Referral certification and authorization
  • Health care claim payments

Covered entities who complete any of these HIPAA transactions electronically are required to use an adopted standard from ASC X12N or NCPDP for certain pharmacy transactions.

Building on the existing HIPAA requirements, in 2010 the Affordable Care Act included additional provisions relating to electronic transactions. When combined, all these provisions are referred to as Administrative Simplification, because they were created with the goal of simplifying the business of healthcare.

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