Section IV: Administrative Standards and Implementation Specifications

Printer Friendly, PDF & Email

Health Care Claims and Coordination of Benefits

Health Care Claims or Equivalent Encounter Information for Professional Claims
Health Care Claims or Equivalent Encounter Information for Institutional Claims
Health Care Claims or Equivalent Encounter Information for Dental 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
Health Care Claim Status Request and Response

Administrative Transactions - Non-Claims

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

Health Plan Premium Payments for Covered Members
Health Care Payment and Remittance Advice
Electronic Funds Transfer for Payments to Health Care Providers

Administrative Transactions to Support Clinical Care

Referral Certification and Authorization Request and Response for Dental, Professional and Institutional Services
Health Care Attachments to Support Claims, Referrals and Authorizations
Referral Certification and Authorization for Pharmacy Transactions

Operating Rules to Support Administrative Transactions

Operating Rules to Support Eligibility Transactions (Phase I)
Operating Rules to Support Eligibility and Claim Status Transactions (Phase II)
Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) for Payments and Reconciliation (Phase III)
Operating Rules to Support Electronic Prescribing Transactions
Operating Rules for Claims, Enrollment, and Premium Payments (Phase IV)

CMS Interoperability Standards for Provider to Provider Communication

Durable Medical Equipment/Home Health Agency Order Submission
Durable Medical Equipment/Home Health Agency Document Request
Durable Medical Equipment/Home Health Agency Signature Request