Standards for Electronic Transactions and Code Sets

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Secretary
45 CFR Parts 160 and 162
[HCFA-0149-F]
RIN 0938-AI58

Health Insurance Reform: Standards for Electronic Transactions

AGENCY: Office of the Secretary, HHS.

ACTION: Final rule.

SUMMARY: This rule adopts standards for eight electronic transactions and for code sets to be used in those transactions. It also contains requirements concerning the use of these standards by health plans, health care clearinghouses, and certain health care providers.

The use of these standard transactions and code sets will improve the Medicare and Medicaid programs and other Federal health programs and private health programs, and the effectiveness and efficiency of the health care industry in general, by simplifying the administration of the system and enabling the efficient electronic transmission of certain health information. It implements some of the requirements of the Administrative Simplification subtitle of the Health Insurance Portability AND ACCOUNTABILITY ACT OF 1996.

DATES: The effective date of this rule is October 16, 2000. The incorporation by reference of certain publications listed in this rule is approved by the Director of the Federal Register as of October 16, 2000.

FOR FURTHER INFORMATION CONTACT:

Pat Brooks, (410) 786-5318, for medical diagnosis, procedure, and clinical code sets.

Joy Glass, (410) 786-6125, for the following transactions: health claims or equivalent encounter information; health care payment and remittance advice; coordination of benefits; and health claim status.

Marilyn Abramovitz, (410) 786-5939, for the following transactions: enrollment and disenrollment in a health plan; eligibility for a health plan; health plan premium payments; and referral certification and authorization.

SUPPLEMENTARY INFORMATION:

Availability of Copies

To order copies of the Federal Register containing this document, send your request to: New Orders, Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date of the issue requested and enclose a check or money order payable to the Superintendent of Documents, or enclose your Visa or Master Card number and expiration date. Credit card orders can also be placed by calling the order desk at (202) 512-1800 or by faxing to (202) 512-2250. The cost for each copy is $8. As an alternative, you can view and photocopy the Federal Register document at most libraries designated as Federal Depository Libraries and at many other public and academic libraries throughout the country that receive the Federal Register. You may also obtain a copy from the following web sites:

http://www.access.gpo.gov/su_docs/aces/aces140.html

http://aspe.hhs.gov/admnsimp/