Administrative Requirements

Applicability.

This provision specifies that covered entities must comply with the administrative requirements set forth in the part.

General requirements.

This provision requires covered entities to use adopted medical and nonmedical data code sets when conducting covered transactions.

Medical data code sets.

The Secretary adopts the following maintaining organization's code sets as the standard medical data code sets:

Valid code sets.

This provision clarifies that code sets are valid within the dates specified by the maintaining organization.

Definitions.

For purposes of this part, the following definitions apply:

Health care claims or equivalent encounter information transaction.

The health care claims or equivalent encounter information transaction is the transmission of either of the following:

Standards for health care claims or equivalent encounter information transaction.

This provision adopts specific standards for electronic health care claims and encounter information transactions, including NCPDP and ASC X12 standards.

Eligibility for a health plan transaction.

This provision defines the eligibility for a health plan transaction as the transmission of an inquiry regarding benefit plan information and the corresponding response.

Standards for eligibility for a health plan transaction.

This provision establishes the mandatory electronic standards for health plan eligibility benefit inquiries and responses.

Operating rules for eligibility for a health plan transaction.

This provision adopts specific CAQH CORE operating rules for health plan eligibility transactions to ensure consistency in electronic data exchange.

Referral certification and authorization transaction.

This provision defines the scope of referral certification and authorization transactions between health care providers and health plans.

Standards for referral certification and authorization transaction.

This provision mandates the electronic standards for referral certification and authorization transactions between providers and health plans.

Health care claim status transaction.

This provision defines the health care claim status transaction as the electronic exchange of claim status inquiries and responses between providers and health plans.

Standards for health care claim status transaction.

This provision mandates the electronic standards for health care claim status inquiries and responses.

Operating rules for health care claim status transaction.

This provision adopts CAQH CORE operating rules for health care claim status transactions to ensure standardized electronic data exchange.

Enrollment and disenrollment in a health plan transaction.

This provision defines the enrollment and disenrollment in a health plan transaction as the electronic transmission of subscriber information to establish or terminate coverage.

Standards for enrollment and disenrollment in a health plan transaction.

This provision mandates the electronic standards for enrollment and disenrollment in a health plan transaction.

Health care electronic funds transfers (EFT) and remittance advice transaction.

This provision defines the health care electronic funds transfer and remittance advice transaction as the electronic transmission of payment and remittance information from health plans to providers.

Standards for health care electronic funds transfers (EFT) and remittance advice transaction.

This provision establishes the technical standards for electronic funds transfers and remittance advice transactions under HIPAA Administrative Simplification.

Operating rules for health care electronic funds transfers (EFT) and remittance advice transaction.

This provision adopts specific operating rules for electronic funds transfers and remittance advice transactions.

Health plan premium payments transaction.

This provision defines the scope of the health plan premium payment transaction for HIPAA administrative purposes.

Standards for health plan premium payments transaction.

This provision mandates the standards for the health plan premium payment transaction.

Coordination of benefits transaction.

This provision defines the coordination of benefits transaction for the purpose of determining payment responsibilities.

Standards for coordination of benefits information transaction.

This provision establishes the standards for coordination of benefits information transactions, including institutional and professional claims.

Medicaid pharmacy subrogation transaction.

This provision defines the Medicaid pharmacy subrogation transaction for seeking reimbursement from health plans.

Standard for Medicaid pharmacy subrogation transaction.

This provision adopts the standards for the Medicaid pharmacy subrogation transaction.

[Reserved]

This provision is reserved.

Compliance dates of the implementation of the standard unique health identifier for health care providers.

This provision sets the compliance dates for the implementation of the National Provider Identifier (NPI) for health care providers, plans, and clearinghouses.

Standard unique health identifier for health care providers.

Defines the National Provider Identifier (NPI) as the standard unique health identifier for health care providers.

National Provider System.

Outlines the functions of the National Provider System (NPS) regarding the assignment, maintenance, and deactivation of National Provider Identifiers.

Implementation specifications: Health care providers.

Specifies requirements for covered health care providers to obtain, use, and disclose their NPIs in standard transactions.

Implementation specifications: Health plans.

Requires health plans to use the NPI of health care providers in all standard transactions where an identifier is required.

Implementation specifications: Health care clearinghouses.

Requires health care clearinghouses to use the NPI of health care providers in all standard transactions where an identifier is required.

Compliance dates of the implementation of the standard unique employer identifier.

Sets the compliance deadlines for health care providers, health plans, and clearinghouses regarding the use of the standard unique employer identifier.

Standard unique employer identifier.

Adopts the Employer Identification Number (EIN) as the standard unique employer identifier for health care transactions.

Implementation specifications for covered entities.

Specifies the use of the Employer Identification Number (EIN) by covered entities in standard transactions.

[Reserved]

This section is reserved.

Maintenance of standards and adoption of modifications and new standards.

Describes the process for designating Designated Standards Maintenance Organizations (DSMOs) and the procedures for modifying or adopting new health care standards.

Trading partner agreements.

A covered entity must not enter into a trading partner agreement that alters standard data elements, adds unauthorized data, uses prohibited codes, or changes the intent of HIPAA transaction implementation specifications.

Availability of implementation specifications and operating rules.

This provision identifies the technical standards and operating rules incorporated by reference for HIPAA-covered electronic transactions, including claims, eligibility, and payment advice.

Requirements for covered entities.

Covered entities must conduct transactions using adopted electronic standards and must ensure business associates comply with these requirements.

Additional requirements for health plans.

Health plans must accept standard transactions, maintain coordination of benefits data, and process valid code sets without imposing excessive fees or discriminatory practices.

Additional rules for health care clearinghouses.

Health care clearinghouses acting as business associates may translate standard and nonstandard transactions on behalf of covered entities.

Exceptions from standards to permit testing of proposed modifications.

Organizations may request exceptions from HIPAA standards to test proposed modifications, subject to Secretary approval and reporting requirements.