Trading Partners

HIPAA Transactions and Code Sets

Transaction Definitions

Health Claims (ANSI ASC X12 837 v4010A1)

This transaction is used to electronically submit health care claims or encounters.  It contains the necessary information for a payer to ajudicate a claim.  By Oct. 16, 2003, any payer must be able to accept this format for claims. 

Coordination of Benefits (COB) is the mechanism developed to prevent duplication of payment when a person is covered by more than one insurance plan/payer.  It limits the total benefits received to no more than the actual amount incurred for care, or to something less than actual amount incurred for care.  It does this by information all subsequent payers in the billing chain, or the benefits determined and/or paid by all previous payers.

Electronic Remittance Advices (ANSI ASC X12 835 v 4010A1)

This transaction allows remittance advice information to be received electronically in a standard format.  With programming by a vendor, this transaction has the ability to post payment information to a practice management system without manual intervention.  This can greatly improve the efficiency of your office environment.

Eligibility (ANSI ASC X12 270/271 v4010A1)

Currently, providers spend a significant amount of time on the telephone verifying patient eligibility and obtaining policy coverage information.  The 270/271 transaction will allow providers to electronically transmit a request for patient eligibility and coverage verification to a payer and receive an electronic response for each patient.

Because the format will be standard, providers will eventually be able to acquire software that will accept the transmission and post the information to the patient accounts with minimal intervention.

Health Care Claim Status (ANSI ASC X12 276/277 v4010A1)

This transaction will allow providers to verify through a batch transmission the status of several claims.  The response will convey that the claim has been paid, denied or is in process through the use of Claim Status Codes and Claims Status Category Codes. 

It is important to note that the information relayed in the 276/277 will not be as detailed as that given in the 835 transaction.  The 835 will provide the claim payment information similar to what is currently conveyed through the provider remittance advices and, therefore, is sent only upon completion of the claim.  The 276/277 will allow providers to track the progress of the claim through the processing system.

Referral Certification and Authorization (ANSI ASC 278 X12 v4010A1)

This transaction allows providers to submit referrals and pre-certification notifications to health plans through a batch transmission.  Vendor programming will be needed to develop the entry screens in your office.  Programming will also be needed to review the reponse to your referral or precertification request.

Enrollment/Disenrollment (ANSI ASC X12 834 v4010A1)

This transaction will be used for enrollment and disenrollment in a health plan.  This transaction will be used by employer groups or their clearinghouses/agents.

Health Plan Premium Payments (ANSI ASC X12 820 v4010A1)

This transaction will be used only for detail remittance information about individual for whom premiums are being paid.  This transaction will be used by employer groups or their clearinghouses/agents.