Transactions Under Health Insurance Portability and Accountability Act

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 Department of Health Care Policy & Financing (Department).

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 Health First Colorado) 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. Health First Colorado 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.