HIPAA Standards for Claims

by  Find-A-Code
June 29th, 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. The following are the claims transactions and the implementation guides adopted as standards under HIPAA:

Standard Claim Transaction Short Reference Implementation Guide Type of Claim
ASC X12 Health Care Claim: Professional (837) ASC X12 837 professional claim ASC X12 Standards for Electronic Data Interchange Technical Report Type 3— Health Care Claim: Professional (837) Professional services and supplies, including retail pharmacy
ASC X12 Health Care Claim: Institutional (837) ASC X12 837 institutional claim ASC X12 Standards for Electronic Data Interchange Technical Report Type 3— Health Care Claim: Institutional (837) Institutional
Telecommunication Standard, National Council for Prescription Drug Programs and equivalent Batch Standard, National Council for Prescription Drug Programs Depending upon context: NCPDP claim; NCPDP transaction; NCPDP batch transaction; NCPDP batch claim Telecommunication Standard Implementation Guide and equivalent Batch Standard Implementation Guide, National Council for Prescription Drug Programs. Retail pharmacy professional services and supplies; retail pharmacy drugs

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:

HIPAA Standards for Claims. (2015, June 29). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/hipaa-standards-for-claims-26964.html

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