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Transactions Under HIPAA

The HIPAA rules for Standard for Electronic Transactions became effective on October 16, 2000. Prior to its implementation, health care providers and plans used many different electronic formats for a variety of electronic transactions. Under HIPAA, the electronic transactions final rule adopted eight electronic transaction standards, all now implemented by the CO Medicaid Program.


The rules require health care providers that send transactions such as inquiries of eligibility or claims for payment electronically to use the standards adopted by this rule.  It requires health care plans (including the CO Medicaid Program) to accept electronically submitted transactions using only these standards.  (Note that acceptance of a claim does not ensure that it will be paid.)

 

The electronic transaction standards required by HIPAA implement Electronic Data Interchange (EDI) solutions based on standards from the American National Standard Institute (ANSI).  In 1979, ANSI chartered the accredited Standards Committee to develop uniform standards for inter-industry electronic exchange of business transactions.


Many providers can avoid the direct adoption of these standards by using a health care clearinghouse that has already done so or by using direct data entry offered by a health plan. The provider must however require that the clearing house complies with these standards. A list of CO Medicaid Program approved vendors of HIPAA compliant transactions services can found at Approved Vendors List (05/07) in the EDI Support section of the Provider Services area of these pages.  The CO Medicaid Program offers a HIPAA compliant direct data entry portal to its providers.
 
The following types of transactions can be accomplished by direct data entry or batch entry:

  • Health Care Eligibility Benefit Inquiry and Response      270/271
  • Health Care Claim Status Request and Response      276/277
  • Health Care Services Review Request                                   278
  • Premium Payment                                                                      820
  • Benefit Enrollment and Maintenance                                      834
  • Health Care Claim Payment and Advice                                 835
  • Health Care Claims and Encounters                                      837
  • Privacy Under HIPAA

Technical specifications of each type of transaction can be obtained from a number of sources.