What are HIPAA standardized transactions?

The HIPAA standardized transactions are a set of standards that cater to the electronic exchange of patient-identifiable information. The rule is set on electronic data interchange standards, allowing the online exchange of health information from device to device without human intervention.

837 Health Care Claims

Providers use the 837 code to submit healthcare claims electronically. Compliance requires using HIPAA-defined, compliant code sets.

835 Health Care Claim Payment/Remit Advice

Payers employ the 835 code to send providers electronic remittance advice or electronic payment explanations. Cigna HealthcareSM utilizes the ERA part for this transaction, and providers must request an 835 through their Clearinghouse.

270/271 Inquiry/Response for Eligibility

This code facilitates checking subscriber or dependent eligibility and benefits, involving 270 inquiries and 271 responses for real-time queries.

276/277 Inquiry/Response for Claim Status

Providers use the 276 code to request the status of a submitted claim, with the 277 response providing real-time status updates.

278 Referral Certification, Authorization, Extensions, and Appeals

This code handles certification for patient health services, authorizations for patient referral to specialists, extensions to previously approved authorizations, pre-certifications, and referrals.

131 International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

Describes a classification system for morbidity and mortality information.

132 National Uniform Billing Committee (NUBC) Codes

Specifies hospital charge classifications and service locations.

134 National Drug Code

Identifies FDA-approved prescription drugs with over 170,000 codes on file.

135 American Dental Association Codes

Contains numeric codes for dental procedures and nomenclature.

139 Claim Adjustment Reason Code

Explains the reasons behind adjustments to healthcare claim payments.

229 Diagnosis-Related Group Number (DRG)

Classifies patients based on their illnesses and medical problems.

235 Claim Frequency Type Code

Explains the frequency of bill submissions.

240 National Drug Code by Format

Includes manufacturing and labeling information for drugs.

245 National Association of Insurance Commissioners (NAIC) Code

Uniquely identifies insurance companies.

307 National Association of Boards of Pharmacy Number

Assigns unique numbers to individual pharmacy locations billing third-party drug benefit payers.

411 Remittance Remark Codes

Provides non-financial information crucial for understanding health insurance claim adjudication.

513 Home Infusion EDI Coalition (HIEC) Product/Service Code List

Identifies home infusion therapy products and services.

530 National Council for Prescription Drug Programs Reject/Payment Codes

Lists NCPDP’s payment and rejects reason codes for electronic prescription claims.

537 Health Care Financing Administration National Provider Identifier

Developed for health care provider identification under HIPAA.

540 Health Care Financing Administration National Plan ID

Developed for health plan identification under HIPAA. These standardized codes play a vital role in electronic healthcare transactions, ensuring compliance with HIPAA regulations.