Electronic Transactions

HIPAA transactions are the electronic transfer of health care information for specific purposes. Under HIPAA, if a health care provider engages in one of the identified transactions, they must comply with the standards for that transaction. HIPAA requires every provider who does business electronically to use the same health care transactions, code sets, and identifiers.

The electronic transaction standards for the healthcare industry are specified by the ASC X12N Subcommittee of The American National Standards Institute (ANSI) and the National Council for Prescription Drug Programs (NCPDP). The NCPDP standard formats are used by retail pharmacies for drug claim transactions.

The following is a list of the electronic transaction standards mandated by HIPAA:

• For claims or encounters:

  • ASC X12N 837 Institutional (versions 4010X096A1 and 5010X223A2)

  • ASC X12N 837 Dental (versions 4010X097A1 and 005010X224A2)

  • ASC X12N 837 Professional (versions 4010X098A1 and 005010X222A1)

• For Remittance Advice

  • ASC X12N 835 (versions 4010X091A1 and 005010X221A1)

  • ASC X12N 820 (versions 4010X061A1 and 005010X218)

• Eligibility Inquiry and Response

  • ASC X12N 270 (versions 4010X092A1 and 5010X279A1)

  • ASC X12N 271 (versions 4010X092A1 and 5010X279A1)

• Prior Authorization and Referral

  • ASC X12N 278 (versions 4010X094A1 and 005010X217)

• Claims Status Inquiry and Response

  • ASC X12N 276 (versions 4010X093A1 and 005010X212)

  • ASC X12N 277 (versions 4010X093A1 and 005010X212)

• Benefit Enrollment and Maintenance

  • ASC X12N 834 (versions 4010X095A1 and 005010X220A1)

• NCPDP retail pharmacy transactions (version 5.1 for telecommunications, version 1.1 for batch transactions)