Standards for Provider Use of Healthcare Transactions, Code Sets, and Identifiers
Simplifying the Claims Process
United States HIPAA requirements specify that all electronic data interchange formats be standardized. This includes uniform definitions of the data elements that will be exchanged in each type of electronic transaction as well as identification of the specific codes or values that are valid for each data element.
Who is Impacted/Included?
The Electronic Transactions & Code Sets Rule applies to:
"...any health plan, any healthcare clearinghouse, and any healthcare provider that transmits any health information in electronic form in connection with the defined transactions.”
What is Included?
The scope of electronic transactions includes:
 | Electronic transmissions using all media, even when the transmission is physically moved from one location to another using magnetic tape, disk, or CD media. |
 | Transmissions over the Internet (public network), extranet (private network using Internet technology to link a business with collaborating parties), leased lines, dial-up lines, and private networks. Telephone voice response and "faxback" systems would not be included. |
What is an Electronic Transaction?
HIPAA defines electronic data interchange transactions as:
- Health claims or similar encounter information
- Healthcare payment & remittance advice
- Coordination of Benefits
- Health claim status
- Enrollment & dis-enrollment in a health plan
- Eligibility for a health plan
- Health plan premium payments
- Referral certification & authorization
What are the Code Set Requirements?
When conducting a transaction covered by this rule, a Covered Entity must meet the following Code Set requirements:
ICD-9-CM CPT-4 Alpha Numeric HCPCS CDT-2 NDC | International Classification of Diseases
Physician Current Procedural Terminology
Healthcare Financing and Administration Procedure Coding System
Current Dental Terminology
National Drug Codes for pharmacy claims |
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