Section IV: Administrative Standards and Implementation Specifications

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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

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

Operating Rules for Claims, Enrollment, and Premium Payments (Phase IV)
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 to Support Eligibility and Claim Status Transactions (Phase II)
Operating Rules to Support Eligibility Transactions (Phase I)