Interoperability API Standards

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45 CFR § 162.1000

General requirements.

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

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45 CFR § 162.1002

Medical data code sets.

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

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45 CFR § 162.1011

Valid code sets.

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

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45 CFR § 162.103

Definitions.

For purposes of this part, the following definitions apply:

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45 CFR § 162.1101

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:

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45 CFR § 162.1102

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.

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45 CFR § 162.1201

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.

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45 CFR § 162.1202

Standards for eligibility for a health plan transaction.

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

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45 CFR § 162.1203

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.

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45 CFR § 162.1301

Referral certification and authorization transaction.

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

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45 CFR § 162.1302

Standards for referral certification and authorization transaction.

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

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45 CFR § 162.1401

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.

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45 CFR § 162.1402

Standards for health care claim status transaction.

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

Citation

45 CFR § 162.1403

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.

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45 CFR § 162.1501

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.

Citation

45 CFR § 162.1502

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.

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45 CFR § 162.1601

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.

Citation

45 CFR § 162.1602

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.

Citation

45 CFR § 162.1603

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.

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45 CFR § 162.1702

Standards for health plan premium payments transaction.

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

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45 CFR § 162.1802

Standards for coordination of benefits information transaction.

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

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45 CFR § 162.1902

Standard for Medicaid pharmacy subrogation transaction.

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

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45 CFR § 162.404

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.

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45 CFR § 162.406

Standard unique health identifier for health care providers.

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

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45 CFR § 162.408

National Provider System.

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

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45 CFR § 162.410

Implementation specifications: Health care providers.

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

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45 CFR § 162.412

Implementation specifications: Health plans.

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

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45 CFR § 162.414

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.

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45 CFR § 162.600

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.

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45 CFR § 162.605

Standard unique employer identifier.

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

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45 CFR § 162.610

Implementation specifications for covered entities.

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

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45 CFR § 162.910

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.

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45 CFR § 162.915

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.

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45 CFR § 162.920

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.