Section IV: Administrative Standards and Implementation Specifications

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Administrative Transactions - Non-Claims

Administrative Transaction Acknowledgements

Enrollment and Disenrollment in a Health Plan

Health Care Eligibility Benefit Inquiry and Response

Health Care Eligibility Benefit Inquiry and Response for Retail Pharmacy Coverage

Administrative Transactions to Financial Exchanges

Electronic Funds Transfer for Payments to Health Care Providers

Health Care Payment and Remittance Advice

Health Plan Premium Payments for Covered Members

Administrative Transactions to Support Clinical Care

Health Care Attachments to Support Claims, Referrals and Authorizations

Referral Certification and Authorization for Pharmacy Transactions

Referral Certification and Authorization Request and Response for Dental, Professional and Institutional Services

CMS Interoperability Standards for Provider to Provider Communication

Durable Medical Equipment/Home Health Agency Document Request

Durable Medical Equipment/Home Health Agency Order Submission

Durable Medical Equipment/Home Health Agency Signature Request

Health Care Claims and Coordination of Benefits

Health Care Claim Status Request and Response

Health Care Claims or Equivalent Encounter Information for Dental Claims

Health Care Claims or Equivalent Encounter Information for Institutional Claims

Health Care Claims or Equivalent Encounter Information for Professional Claims

Health Care Claims or Equivalent Encounter Information for Retail Pharmacy Claims

Health Care Claims or Equivalent Encounter Information for Retail Pharmacy Supplies and Professional Services

Operating Rules to Support Administrative Transactions

Eligibility and Benefits Operating Rules for Standard Transactions

Operating Rules for Benefit Enrollment

Operating Rules for Claims

Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) for Payments and Reconciliation

Operating Rules for Premium Payments

Operating Rules for Prior Authorization and Referrals

Operating Rules to Support Claim Status Transactions

Operating Rules to Support Electronic Prescribing Transactions