Health Care Transactions Basics (PDF)

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ABOUT ADMINISTRATIVE SIMPLIFICATION Health Care Transactions Basics What is a Health Care Transaction? Administrative Simplifcation Standard A health care transaction is an Transactions exchange of information between To help guide the health care industry, the two parties to carry out financial Department of Health and Human Services (HHS) adopted or administrative activities. When standardized implementation specifications for electronic electronic health care transactions transactions used in the electronic exchange of health care data. are used effectively, they: These adopted transactions include: • Increase efficiencies in operations • Health care claim X12N 837 transaction • Improve the quality and accuracy • Health care claim payment advice X12N 835 transaction of information • Health care claim status request/notifcation X12N 276/277 transaction • Reduce the overall costs to the • Eligibility, coverage, or beneft inquiry/information X12N 270/271 health care system transaction Widespread use of Healthcare • Beneft enrollment and maintenance X12N 834 transaction Insurance Portability and • Health care service review information X12N 278 transaction Accountability Act of 1996 • Payment order/remittance advice X12N 820 transaction (HIPAA) adopted transactions— HIPAA-covered entities—health plans, clearinghouses, and covered where everyone uses the same health care providers—must use the adopted standards when language, format, and code sets— conducting these transactions using an electronic format. can lead to substantial savings For several of these transactions, HHS has also adopted across the health care industry. operating rules that support the use of transactions. To realize these benefits, however, all organizations need to be using the same adopted standards for their health care transactions. Enforcement The National Standards Group (NSG) enforces compliance with Administrative Simplification standards and operating rules on behalf of the Department of Health and Human Services. Information about enforcement, compliance, and fling complaints can be found on the CMS website. Visit Our Website To find out more, visit Go.CMS.gov/AdminSimp and sign up for Administrative Simplification Email Updates. .

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