Health Care Claims or Equivalent Encounter Information for Professional Claims

Printer Friendly, PDF & Email
Type Standard / Implementation Specification Standards Process Maturity Implementation Maturity Adoption Level Federally required Cost Test Tool Availability
Implementation Specification
Rating 5
Limitations, Dependencies, and Preconditions for Consideration
Applicable Security Patterns for Consideration
  • The Administrative Simplification provisions of HIPAA apply to the adoption of electronic transaction standards and operating rules for use in the health care industry. HIPAA has some different requirements for information exchange than EHRs, but there is hope for convergence in the future.  Information about the HIPAA regulations regarding standards and operating rules can be found at Readers can find information about requirements for covered entities and their business associates and enforcement from this link.
  • This standard and the transaction were adopted under the Health Insurance Portability Act of 1996 (HIPAA) to increase efficiency in the health care system by reducing the use of paper and increasing the exchange of health care information electronically. The current version was adopted in 2009, and required for use in 2012. Content from the transactions is often maintained in provider practice management and billing systems but duplicates information in electronic health records.
  • Before implementation of a new version of a standard, end to end testing should be conducted with vendor systems and between trading partners to ensure changes have been accommodated.
  • Additional information is available on testing, and the full cost on any of the X12 transactions. ASETT is the HHS compliance tool to enable testing and complaint filing for all X12 and NCPDP transactions.



  • All covered entities and their business associates are required to comply with the HIPAA Privacy and Security Rules. Health and Human Services has partnered with the Office of the National Coordinator and the National Institutes of Standards and Technology to publish comprehensive guidance for Security specific to electronic protected health information. A self-assessment tool kit is available to support integrating privacy and security into practices. 


The use of standards based…

The use of standards based on 30 year-old UN-EDIFACT based standards needs consideration.  They work, but quite frankly, take a mountain of healthcare specific training to adopt. The payment industry needs to consider pilots for moving towards RESTFUL based APIs for payment based transactions across the board, in both batch and real-time formats.  It takes 5-10 years simply to adopt a new version of these standards to change the width of some fields and accommodate new coding or identifier systems 

CMS Response

CMS Response: We appreciate the feedback and look forward to receiving specific recommendations from industry for the use of alternative standards that enable the electronic exchange of health care information. The HIPAA regulations encourage pilots to test the use of alternative standards which meet the objectives of administrative simplification.