HIPAA Standards for Claims

by 
July 20th, 2015

(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014)

The standards adopted under HIPAA include both a transaction standard and an implementation guide. 

Claims sent electronically to Medicare must abide by the HIPAA standards listed above. The current versions of these HIPAA standards are listed in chapter 24 of this manual. More information about HIPAA can be found at www.cms.gov, under the “Regulations and Guidance” tab. More information about these transactions and implementation guides can be found, as appropriate, at www.X12.org and www.NCPDP.org.

In addition, chapter 24 of this manual provides more information regarding Medicare’s requirements for electronic data interchange (EDI), such as EDI enrollment and trading partner agreements.

Note that HIPAA standard implementation guides provide comprehensive directions regarding how to submit a claim on the transactions they support. Therefore, there is no separate guidance in this claim processing manual as to how to submit a claim using these transactions. However, there may be situations where the Medicare requirements require additional clarification, description, or guidance. In such cases, there will be additional instructions in the appropriate subject area section. 

References:

• Pub 100-04 Medicare Claims Processing