Health Care Payment and Remittance Advice

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Type Standard / Implementation Specification Standards Process Maturity Implementation Maturity Adoption Level Federally required Cost Test Tool Availability
Standard
Final
Production
Rating 3
Yes
$
Yes
Implementation Specification
Final
Production
Rating 3
Yes
$
Yes
Limitations, Dependencies, and Preconditions for Consideration Applicable Value Set(s) and Starter Set(s)
  • 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 https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/HIPAA-ACA/index.html. Readers can find information about requirements for covered entities and their business associates and enforcement from this link.
  • Adoption of standards to increase the efficiency of the health care system was required by the Health Insurance Portability Act of 1996 (HIPAA). This version of the standard was adopted in 2009, and compliance was required by January 2012. The purpose of the electronic standard transactions was to improve efficiency in the health care system by reducing the use of paper and increasing the electronic exchange of health care information.   
  • Challenges with this transaction may occur when the remittance information does not match the claim or the payment.
  • 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.
  • Pharmacy providers will receive the X12 835 remittance advice transaction with their payments, and NCPDP offers specific guidance on how the X12 835 remittance advice should be mapped in response to the NCPDP D.0 claim transaction to maximize reconciliation.
  • 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.

Comment

NCPDP - Comment

Limitations, Dependencies, and Preconditions for Consideration:  NCPDP provides specific guidance on how the ASC X12N 835 should be mapped in response to a NCPDP Version D.0 transaction.