HIPAA Implementation Guide Summary

Health Care Claim: Professional (837)

This transaction is used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billing services and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits (COB) is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.

The information required for this document can also be found on HCFA-1500 Forms

Health Care Claim: Institutional(837)

This transaction is used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billing services and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits (COB) is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.

Health Care Claim: Dental (837)

This transaction is used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billing services and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits (COB) is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.

Health Care Eligibility Benefit Inquiry and Response (270/271)

The Health Care Eligibility and Benefit transactions are designed so that inquiry submitters (information receivers) can determine (a) whether an information source organization (e.g., payer, employer, HMO) has a particular subscriber or dependent on file, and (b) the health care eligibility and/or benefit information about that subscriber and/or dependent(s). The data available through these transaction sets is used to verify an individual’s eligibility and benefits, but cannot provide a history of benefit use. The information source organization may provide information about other organizations that may have third party liability for coordination of benefits. Note, the identification of subscriber/dependent and associated relationship code values may or may not be the values needed to determine primary/secondary coverage for coordination of benefits on
claims transactions.

Health Care Claim Status Request and Response (276/277)

This implementation guide addresses the paired usage of the 276 as a request for claim status and the 277 as a response to that request. The 276 is used to transmit request(s) to obtain the status of specific health care claim(s) within a payer’s adjudication process. The payer uses the 277 to transmit the current system status of those requested claims.

Health Care Services Review — Request for Review and Response (278)

This implementation guide handles the following business cases

• Health care admission certificate requests and responses
• Referral requests and responses
• Health care services certification requests and responses
• Extend certification requests and responses
• Certification appeal requests and responses

Payroll Deducted and Other Group Premium Payment for Insurance Products (820)

Companies and government agencies that offer employees group life, health, and disability insurance can use a subset of the 820 to provide remittance detail associated with the premium payments. The premium being remitted can be associated with health
care, individual life, disability, and/or property and casualty contracts. This transaction can be used for non-covered contributions associated with account-based health arrangements such as health savings accounts.
The 820 can be used in the following ways:

1. Initiate an electronic payment that includes the remittance detail needed by the premium receiver to properly apply the payment.
2. Initiate a payment without the remittance detail, and send the remittance detail separately to the premium receiver. The payment can be an electronic payment or a paper check.

Benefit Enrollment and Maintenance (834)

This implementation guide is used to transfer enrollment information from the sponsor of insurance coverage, benefits, or policy to a payer.

Health Care Claim Payment/Advice (835)

The 835 is intended to meet the particular needs of the health care industry for the payment of claims and transfer of remittance information. The 835 can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice from a payer to a payee, either directly or through a DFI.

Acknowledgement for Health Care Insurance (999)

This implementation guide is intended to be used for reporting syntactical errors against a functional group based on an implementation guide or report the receipt of a functional group that fully complies with a implementation guide