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  HIPAA EDI Covered Transactions  


Below is a listing of the HIPAA EDI Transaction Sets. For all applicable sets, BMS is either currently compliant or will become compliant prior to the October 2003 effective date.

Covered Transactions - Description Transaction Standard
The referral certification and authorization transaction is any of the following transmissions: A) A request for review of health care to obtain an authorization for the health care, B) A request to obtain authorization for referring an individual to another health care provider, C) A response to a request described in paragraph A) or paragraph B) of this section. ASC X12N 278
Health Care Services Review Request for Review & Response, Version 4010
The eligibility for a health plan is the transmission of either of the following: A) an inquiry from a health care provider to a health plan, or from one health plan to another health plan, to obtain any of the following information about a benefit enrollee: 1. Eligibility to receive health care under the health plan, 2. Coverage of health care under the health plan, 3. Benefits associated with the benefit plan, B) A response from a health plan to a health care providers (or another health plan's) inquiry described in paragraph A) of this section. ASC X12N 270/271
Health Care Eligibility Benefit Inquiry and Response, Version 4010
The enrollment and disenrollment in a health plan transaction is the transmission of subscriber enrollment information to a health plan to establish or terminate insurance coverage. ASC X12N 834
Benefit Enrollment & Maintenance, Version 4010
The health care payment and remittance advice transaction is the transmission of either of the following for health care: A) The transmission of any of the following from a health plan to a health care provider's financial institution; 1) Payment, 2) Information about the transfer of funds, 3) Payment processing information, B) The transmission of either of the following from a health plan to a health care provider; 1) Explanation of benefits, 2) Remittance advice. ASC X12N 835
Professional Health Care Claim Payment/Advice, Version 4010
The health care payment and remittance advice transaction is the transmission of either of the following for health care: A) The transmission of any of the following from a health plan to a health care provider's financial institution; 1) Payment, 2) Information about the transfer of funds, 3) Payment processing information, B) The transmission of either of the following from a health plan to a health care provider; 1) Explanation of benefits, 2) Remittance advice. ASC X12N 835
Institutional Health Care Claim Payment/Advice, Version 4010
The health care payment and remittance advice transaction is the transmission of either of the following for health care: A) The transmission of any of the following from a health plan to a health care provider's financial institution; 1) Payment, 2) Information about the transfer of funds, 3) Payment processing information, B) The transmission of either of the following from a health plan to a health care provider; 1) Explanation of benefits, 2) Remittance advice. ASC X12N 835
Dental Health Care Claim Payment/Advice, Version 4010
The health plan premium payment transaction is the transmission of any of the following from the entity that is arranging for the provision of health care or is providing health care coverage payments for an individual to a health plan: A) Payment, B) Information about the transfer of funds, C) Detailed remittance information about individuals for whom premiums are being paid, D) Payment processing information to transmit health care premium payments including any of the following: 1) Payroll deductions, 2) Other group premium payments, 3) Associated group premium payment information. ASC X12N 820
Payroll Deducted and Other Group Premium Payment for Insurance Products, Version 4010
Claims, Coordination of Benefits, Payment Information ASC X12N 837
Health Care Claim: Professional, Volumes 1 and 2, Version 4010
Claims, Coordination of Benefits, Payment Information ASC X12N 837
Health Care Claim: Institutional, Volumes 1 and 2, Version 4010
Claims, Coordination of Benefits, Payment Information ASC X12N 837
Health Care Claim: Dental, Version 4010
Pharmacy claim NCPDP
Telecommunication Standard Implementation Guide, Version 5, Release 1, September 1999, and Equivalent NCPDP Batch Standard Batch
Pharmacy Remittance and Payment Advice NCPDP
Telecommunication Standard Implementation Guide, Version 5, Release 1, and Equivalent NCPDP Batch Standard Batch Implementation Guide, Version 1, Release 0, Feb 1, 1996
First Report of Injury - NPRM to be published by end of 2001 ASC X12N 148
First Report of Injury, Version 4010
Claims Attachments – NPRM to be published by end of 2001 ASC X12N 275
Claims Attachments, Version 4010

Standard Identifiers - Description Standard
Taxpayer Identification assigned by the Internal Revenue Service. Covered entities must use the standard unique employer identifier (EIN) of the appropriate employer in standard transactions that require and employer identifier to identify a person or entity as an employer, including where situationally required. Standard Unique Employer Identifier

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