New Health Care Electronic Transactions Standards

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
requires the Secretary of the Department of Health and Human Services
(HHS) to adopt standards that covered entities (health plans, health
care clearinghouses, and certain health care providers) must use when
electronically conducting certain health care administrative transactions,
such as claims, remittance, eligibility, and claims status requests
and responses.
Over 99 percent of Medicare Part A claims and over 96 percent of
Medicare Part B claims transactions are received electronically. The
current versions of the standards (the Accredited Standards Committee
X12 Version 4010/4010A1 for health care transactions and the National
Council for Prescription Drug Programs [NCPDP] Version 5.1 for
pharmacy transactions) used in these health care transactions lack certain
functionality required by the health care industry. Therefore, it is necessary
for providers to prepare for new standards in order to continue submitting
claims electronically. This fact sheet provides basic information about the
new transactions standards for the following versions adopted by HHS:
ASC X12 Version 5010, and NCPDP Versions D.0 and 3.0.
What Regulatory Requirements are Responsible for the
Transactions Standards?
• HIPAA mandated that the health
c a r e i n d u s t r y u s e s t a n d a r d
formats for electronic claims and
claims-related transactions.
• The Transactions and Code Sets Final
Rule, published on August 17, 2000,
adopted the International Classification
of Diseases, 9th Revision, Clinical
Modification (ICD-9-CM) as a HIPAA
standard for transactions.