Office of Compliance Programs

Electronic Data Interchange Requirements
(Also known as the Transactions and Codesets Rule)

In order to simplify and therefore reduce the administrative cost of billing electronically, HIPAA specifies new requirements for transaction formats, codesets and standard identifiers. The deadline for complying with the Transaction Rule is October 16, 2002 for large institutions and October 16, 2003 for small businesses. Large institutions can apply for an extension to the October 2003 date by supplying project plan and budgetary information. 

Transactions

HIPAA identifies nine different types of electronic transactions. Each of these transactions must conform to the ANSI X12N standard format specified by the regulations.  

  • Health claims or equivalent encounter information
  • Health claims attachments
  • Enrollment and disenrollment in a health plan
  • Eligibility for a health plan
  • Health care payment and remittance advice
  • Health plan premium payments
  • First report of injury
  • Health claim status
  • Referral certification and authorization

Codesets

The following codesets are required by HIPAA regulations.

International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9CM) Volumes 1 & 2

  • Diseases
  • Injuries
  • Impairments
  • Other health problems and their manifestations
  • Causes of injuries, disease, impairments, or other health problems

International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9CM) Volume 3

  • Prevention
  • Diagnosis
  • Treatment
  • Management

National Drug Code

  • Drugs
  • Biologics

Code on Dental Procedures and Nomenclature

  • Dental Services

A combination of the Health Care Financing Administration's Common Procedure Coding System (HCPCS) and the Common Procedural Terminology, 4th Edition (CPT-4) for all physician services and other health care services including but not limited to:

  • Physician Services
  • Physical and occupational therapy services
  • Radiological procedures
  • Clinical laboratory tests
  • Other medical diagnostic procedures.
  • Hearing and vision services
  • Transportation services including ambulance

Health Care Financing Administration's Common Procedure Coding System (HCPCS) for all other substances, equipment, supplies, or other items used in health care services.   

Standard Identifiers

HIPAA requires regulations to set standard identifiers for healthcare providers, health plans, employers, and, individuals. Regulations governing provider identifiers and employer identifiers have been proposed. Regulations governing health plan identifiers are under development. Individual identifiers are on hold until privacy concerns can be addressed.