What Is a Transaction?

A transaction is an electronic exchange of information between two parties khổng lồ carry out financial or administrative activities related to health care. For example, a health care provider will send a claim to a health plan to lớn request payment for medical services.

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Health Care Transactions Basics (PDF)

Overview document of electronic transactions used in health care lớn increase efficiencies in operations, improve the quality and accuracy of information, và reduce the overall costs lớn the system.

Standards for Transactions

Under HIPAA, HHS adopted certain standard transactions for the electronic exchange of health care data. These transactions include:

Payment & remittance adviceClaims statusEligibilityCoordination of benefitsClaims và encounter informationEnrollment & disenrollmentReferrals & authorizations Premium payment

HIPAA-covered entities who conduct any of these transactions electronically must use an adopted standard from ASC X12N or NCPDP (for certain pharmacy transactions).

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Learn More

Learn more about transactions with the following fact sheets:

Eligibility & Benefits Transaction Savings Fact Sheet (PDF) 

EFT & ERA: Electronic Funds Transfer and Electronic Remittance Advice Transactions Basics (PDF)

Claim Status Basics (PDF)

Health Plan Eligibility và Benefits Transaction Basics (PDF)
Coordination of Benefits Transactions Basics (PDF)

Additional Provisions khổng lồ Simplify the Business of Health Care

In 2010, subsequent legislation introduced additional provisions that addressed the use of transactions, building upon the requirements already in place through HIPAA. Together, the provisions are referred khổng lồ as Administrative Simplification, because their purpose is khổng lồ simplify the business of health care.

The new và expanded provisions included requirements for the adoption of:

Operating rules for each of the existing transactionsA standard unique identifier for health plans Standards for electronic funds transfer & electronic health care claims attachments

These provisions also created a new requirement for health plans to lớn certify their compliance with the adopted standards và operating rules. They also established a new mix of penalties that could be imposed on health plans for failure to lớn comply or to certify their compliance. 

Enforcement of the Administrative Simplification provisions under HIPAA & subsequent legislation falls under HHS and is carried out by the National Standards Group (NSG) at oered.org. Information about enforcement, compliance, and complaints can be found in the section of this website.

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