CMS Pub. 100-04, ch. 1, § 02.1

The standards adopted under HIPAA include both a transaction standard and an

implementation guide. The following are the claims transactions and the implementation

guides adopted as standards under HIPAA:

Standard Claim

Transaction

Short Reference Implementation Guide Type of Claim

ASC X12 Health Care

Claim:

Professional (837)

ASC X12 837

professional

claim

ASC X12 Standards for

Electronic Data Interchange

Technical Report Type 3—

Professional

services and

supplies, including

Standard Claim

Transaction

Short Reference Implementation Guide Type of Claim

Health Care Claim:

Professional (837)

retail pharmacy

ASC X12 Health Care

Claim:

Institutional (837)

ASC X12 837

institutional

claim

ASC X12 Standards for

Electronic Data Interchange

Technical Report Type 3—

Health Care Claim:

Institutional (837)

Institutional

Telecommunication

Standard,

National Council for

Prescription Drug

Programs and equivalent

Batch Standard, National

Council for Prescription

Drug Programs

Depending upon

context: NCPDP

claim; NCPDP

transaction;

NCPDP batch

transaction;

NCPDP batch

claim

Telecommunication

Standard Implementation

Guide and equivalent Batch

Standard

Implementation Guide,

National Council for

Prescription Drug

Programs.

Retail pharmacy

professional

services and

supplies; retail

pharmacy drugs

Claims sent electronically to Medicare must abide by the HIPAA standards listed above.

The current versions of these HIPAA standards are listed in chapter 24 of this manual.

More information about HIPAA can be found at www.cms.gov, under the “Regulations

and Guidance” tab. More information about these transactions and implementation

guides can be found, as appropriate, at the official ASC X12 website and

www.NCPDP.org.

In addition, chapter 24 of this manual provides more information regarding Medicare’s

requirements for electronic data interchange (EDI), such as EDI enrollment and trading

partner agreements.

Note that HIPAA standard implementation guides provide comprehensive directions

regarding how to submit a claim on the transactions they support. Therefore, there is no

separate guidance in this claim processing manual as to how to submit a claim using

these transactions. However, there may be situations where the Medicare requirements

require additional clarification, description, or guidance. In such cases, there will be

additional instructions in the appropriate subject area section.