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2 forms found in the DOM

GET /search/cms

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POST https://public.govdelivery.com/accounts/USCMS/subscribers/qualify

<form aria-label="Enter your email address for email updates" accept-charset="UTF-8" action="https://public.govdelivery.com/accounts/USCMS/subscribers/qualify" id="email-footer-form" method="post"
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Centers for Medicare & Medicaid Services


HEADER

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CMS.GOV MAIN MENU

 * Medicare
 * Medicaid/CHIP
 * Medicare-Medicaid Coordination
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 * Innovation Center
 * Regulations & Guidance
 * Research, Statistics, Data & Systems
 * Outreach & Education
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BREADCRUMB

 * 
 * Regulations & Guidance
 * Administrative Simplification
 * HIPAA and Administrative Simplification
 * Adopted Standards and Operating Rules

 * Admin Simp Overview
 * Guidance
 * Transactions
 * Code Sets
 * Operating Rules
 * Enforcement
 * Unique IDs


PAGES IN THIS SECTION


 * HIPAA AND ADMINISTRATIVE SIMPLIFICATION

 * * Events and Latest News
   * Statutes and Regulations
   * Adopted Standards and Operating Rules
   * Are You a Covered Entity?
   * Privacy and Security Information
   * Standards Adoption Process
   * Standard-Setting and Related Organizations
   * Administrative Simplification FAQs


ADOPTED STANDARDS AND OPERATING RULES




HIPAA required HHS to establish national standards for electronic transactions
to improve the efficiency and effectiveness of the nation's health care system.
  

These standards apply to all HIPAA covered entities:

 * Health plans
 * Health care clearinghouses
 * Health care providers who conduct electronic transactions, not just those who
   accept Medicare or Medicaid

Any provider who accepts payment from any health plan or other insurance company
must comply with HIPAA if they conduct the adopted transactions electronically.

These providers must also have written agreements in place to ensure business
associates comply with HIPAA. Examples of business associates include
clearinghouses and independent medical transcriptionists.

Below is an overview of all the adopted standards for electronic health care
transactions.

Standards

ASC X12 Version 5010 is the adopted standard format for transactions, except
those with retail pharmacies.

For retail pharmacy transactions, HHS adopted two standards from the National
Council for Prescription Drug Programs (NCPDP):

 * Pharmacy and supplier transactions – NCPDP Version D.0
 * Medicaid subrogation – NCPDP Version 3.0

Summaries of adopted standards and operating rules for transactions and code
sets follow.

Adopted Transaction Standards and Operating Rules

 

Transaction

Standard

Federally Mandated Operating Rules

Compliance Date

Health claims (institutional, professional, and dental)

ASC X12N 837 Version 5010 

No

Standard: Jan 1, 2012

Eligibility and benefit verification

ASC X12N 270/271 Version 5010 

Yes

Standard: Jan 1, 2012

Operating rules: Jan 1, 2013

Prior authorization and referrals

ASC X12N 278 Version 5010 

 

Standard: Jan 1, 2012

Claim status inquiry and response

ASC X12N 276/277 Version 5010 

Yes

Standard: Jan 1, 2012

Operating rules: Jan 1, 2013

Claim payment (or EFT, electronic funds transfer)

ACH CCD+Addenda

ASC X12N 835 Version 5010

Yes

ACH standard: Jan 1, 2014

Version 5010 standard: Jan 1, 2012

Operating rules: Jan 1, 2014

Electronic remittance advice (ERA)

TRN Associated Trace Number

ASC X12N 835 Version 5010

Yes

TRN standard: Jan 1, 2014

Version 5010 standard: Jan 1, 2012

Operating rules: Jan 1, 2014

Coordination of benefits

ASC X12N 837 Version 5010

No

Standard: Jan 1, 2012

Referral certification

ASC X12N 278 Version 5010

No

Standard: Jan 1, 2012

Retail pharmacy drug claim submission

NCPDP D.0

No

Standard: Jan 1, 2012

Medicaid pharmacy subrogation

NCPDP 3.0

No

Standard: Jan 1, 2012

 

Enrollment/disenrollment in a health plan

ASC X12N 834 Version 5010

No

Standard: Jan 1, 2012

Premium payment/explanation (employer)

ASC X12N 820 Version 5010

 

No

Standard: Jan 1, 2012

 

Adopted Standard Code Sets

 

Activity

Standard

Diagnosis coding

ICD-10-CM—International Classification of Diseases, 10th edition, Clinical
Modification

Hospital inpatient procedure coding

ICD-10-PCS—International Classification of Diseases, 10th edition, Procedure
Coding System

Outpatient procedure and physician services coding

CPT—Current Procedural Terminology

Supplies/not included in CPT

HCPCS—Healthcare Common Procedure Coding System

Dental procedure coding

CDT—Code on Dental Procedures and Nomenclature

Page Last Modified:
05/26/2022 10:34 AM
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