Health Care Eligibility Benefit Inquiry and Response

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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. This version was adopted in 2009 and mandatory use was required in January 2012. This information 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 transactions.
  • For a description of the functionality of each transaction, visit the X12 website. Click on a transaction set name to toggle the display of the purpose and scope of that transaction set.
  • 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.