What Are HIPAA Transaction and Code Sets Standards?

The HIPAA transaction and code sets standards create a uniform way to perform electronic data interchange (EDI) transactions for submitting, processing, and paying claims. 

The standards applies to "... any health plan, any health care clearinghouse, and any health care provider that transmits any health information in electronic form" in connection with the defined transactions. Within the scope of the transaction standard are: 

  • Electronic transmissions using all media, even when the transmission is physically moved from one location to another using magnetic tape, disk, or CD; and
  • Transmissions over the Internet, extranet (a private network using Internet technology to link business partners), leased lines, dial-up lines, and other private networks.

The standard does not encompass telephone voice response and fax-back systems.

The HIPAA standards covers these EDI health care transactions:

  • Health 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 for a health plan,
  • Health plan premium payments, and
  • Referral certification and authorization.

 HIPAA transactions and code set standards rules are important to consider when evaluating your practice management systems. If you intend to submit claims and conduct other HIPAA transactions electronically, it is essential that you understand the costs involved in complying with the standard formats.

For more information about the HIPAA transaction rule, go to TMA's HIPAA Resource Center and the Transaction and Code Sets Standards section of the Centers for Medicare & Medicaid Services' Website.

Updated Jan. 8, 2013

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