HIPAA Standard Transactions

HIPAA requires the Secretary of Health and Human Services (HHS) to adopt standards to support electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. After looking at all the various transactions in place such as NSF, HHS selected the ANSI transaction set. ANSI is the American National Standards Institute. They provide standards for exchange of business information under the Accredited Standards Committee, ASC X12. X12 has a subcommittee for the insurance industry called ASC X12N. This committee is responsible for maintaining all insurance transaction formats.

HIPAA mandates the following transactions sets be implemented in a standard format:

• 837 - Claims and encounters
• 835 - Payment and remittance advice
• 270/271 - Eligibility inquiry and response
• 275 - Claim attachments
• 276/277 - Claim status and response
• 834 - Enrollment
• 278 - Referral certification and authorization

The number preceding transaction is the ANSI transaction set. Previously, ANSI version 4010-1A was required to be implemented. Version 4010A1 is now required as of October, 2003.

Electronic claims have been traded between providers and health plans since the mid-1980s. Claim transactions today are submitted in National Standard Format (NSF), ANSI or a health plans proprietary format. NSF has never been a standard because each health plan could create their own implementation guide, requiring different information than another health plan.

HIPAA has done away with this and requires all health plans and providers to use the standard implementation guide. However health plans and providers can use a clearinghouse to translate from proprietary formats to standard formats. For instance, a provider could submit claims to a clearinghouse in NSF as long as the clearinghouse can translate the claim into an 837 transaction before going to the health plan. A health plan can continue to use their proprietary format as long as they have a clearinghouse that can accept ANSI transactions from their providers for them.

Any health plan accepting electronic transactions is required to accept those transactions in this standard format.