HIPAA Transaction Standards and Code Sets

Question 1

Which standard electronic transaction format is required under HIPAA for submitting healthcare claims from providers to health plans?

Accepted Answer

X12 837

Answer

The X12 837 is the HIPAA-mandated standard transaction for submitting healthcare claims. X12 835 is for remittance advice, X12 270/271 handles eligibility inquiries and responses, and X12 834 covers benefit enrollment.

Question 2

Under HIPAA Administrative Simplification, which code set is mandated for reporting diagnoses on inpatient hospital claims?

Accepted Answer

ICD-10-CM

Answer

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) is the HIPAA-required code set for diagnoses, including inpatient diagnoses. CPT-4 is used for physician procedures; HCPCS Level II is used for supplies and non-physician services; NDC is for drugs in retail pharmacy transactions.

Question 3

The X12 835 transaction under HIPAA is used for which purpose?

Accepted Answer

Healthcare claim payment and remittance advice

Answer

The X12 835 transaction is the Health Care Claim Payment/Advice, used by payers to communicate payment details and explanations back to providers. Eligibility verification uses X12 270/271, enrollment uses X12 834, and claim submission uses X12 837.

Question 4

Which organization develops and maintains the ASC X12 transaction standards that HIPAA requires for most electronic healthcare transactions?

Accepted Answer

Accredited Standards Committee X12 (ASC X12)

Answer

ASC X12 is the standards development organization that creates and maintains the X12 electronic data interchange (EDI) standards adopted by HIPAA. CMS enforces HIPAA; the AMA maintains CPT codes; ONC oversees health IT policy but does not develop transaction standards.

Question 5

A health plan receives an X12 270 transaction from a provider. What transaction is the health plan required to send in response?

Accepted Answer

X12 271 (eligibility and benefit response)

Answer

The X12 270 is the Health Care Eligibility/Benefit Inquiry transaction, and the paired response is the X12 271, Health Care Eligibility/Benefit Response. X12 835 responds to a claim payment cycle, X12 277 responds to a claim status inquiry (X12 276), and X12 999 acknowledges receipt but is not the substantive reply.

HIPAA - Health Insurance Portability and Accountability Act Practice Test

HIPAA - Health Insurance Portability and Accountability Act Practice Test

HIPAA Transaction Standards and Code Sets