The Health Insurance Portability and Accountability Act's (HIPAA's) Transactions and Code Sets Rule standardizes 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 ( see below ).
The scope of the transaction standard includes:
- 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 rule 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.
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' Web site.
TMA Practice E-tips main page