HIPAA standards

HIPAA X12 standards are a specific subset of the X12 library of standards. Developed within X12N, the Insurance subcommittee of X12, the HIPAA standards provide a strict and unambiguous interpretation of the various HIPAA transactions named in the Final Rule. This interpretation is presented in a format called an Implementation Guide. HIPAA Implementation Guides, sometimes referred to as IGs, document a specific interpretation of the syntax and semantics of each transaction.

HIPAA Implementation Guides

The HIPAA Implementation Guides satisfy several requirements:

Comply with HIPAA and its associated rules
Facilitate a smooth transition to the EDI environment by providing standardized data requirements and content for users of each HIPAA transaction
Allow the electronic exchange of information from computer to computer without human involvement

The following table lists the transaction standards as implemented through the appropriate Guide Addenda. Computer-based transmissions of the following transaction types must comply with the HIPAA standards.

Transaction	Title and use
270/271	Health Care Eligibility Benefit Inquiry and Response Provider uses the 270 to request details of health care eligibility and benefit information or to determine if an information source organization has a particular subscriber or dependent on file. Payer uses the 271 to respond to 270 inquiries.
276/277	Health Care Claim Status Request and Response Provider uses to request the status of health care claims. Payer uses to respond to 276 requests.
275	Additional Information to Support a Health Care Claim or Encounter Provider uses the 275 to send requested information about a claim or encounter.
277	Health Care Claim Request for Additional Information Payer uses the 277 to request additional information about a health care claim or encounter.
278	Health Care Services Review Information Request and Response Health care providers use request transactions to request information on admission certifications, referrals, service certifications, extended certifications, certification appeals, and other related information. Review entities use response transactions to respond to inquiries.
820	Payment Order/Remittance Advice Insurance companies, third-party administrators, payroll service providers, and internal payroll departments use the 820 to transmit premium payment information.
834	Benefit Enrollment and Maintenance Benefit plan sponsors and administrators use the 834 to transmit enrollment and benefits information to each other.
835	Health Care Claim Payment/Advice Payer and provider use the 835 to make payments on a claim, send Explanation of Benefits (EOB) remittance advice, or to send both the payment and EOB in the same transaction.
837	Health Care Claim There are three separate Implementation Guides for 837 Health Care Claims: Dental, Institutional, Professional Each is used by the provider—dentist/dental group, clinic/hospital, and physicians/surgeons—or between payers to submit and transfer claims and encounters to the payer.

Historically, health providers and plans have used many different electronic formats. HIPAA’s primary goal is to simplify the complex process of administration and payment of health care claims by implementing a single transaction standard and establishing the code sets used.

Under the enacted regulations, health plans will be able to reimburse providers, authorize services, certify referrals, and coordinate benefits using a standardized electronic format. Additionally, providers will be able to check eligibility for coverage, check claim status, request referrals and service authorizations, and receive electronic remittance to post receivables.

Who is affected by HIPAA requirements?

HIPAA applies to the following health care organizations:

Health plans
Health care providers, such as hospitals and physicians, that conduct health transactions electronically
Health care clearing houses that convert health care data between HIPAA-compliant and non-compliant formats

Entities that pay health care claims, as well as the providers and clearinghouses exchanging electronic payment information with each other, are affected by HIPAA requirements.

Getting additional information about HIPAA

For more detailed information on HIPAA and the Administrative Simplification provision, see the following Web sites:

HIPAA X12 Implementation Guides are available to download from the Washington Publishing Company Web site.