HIPAA Transaction Standards and Code Sets — Questions and Answers
Question 1: Which standard electronic transaction format is required under HIPAA for submitting healthcare claims from providers to health plans?
- X12 835
- X12 270
- X12 837 (Correct answer)
- X12 834
Correct answer: X12 837
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?
- HCPCS Level II
- ICD-10-CM (Correct answer)
- CPT-4
- NDC (National Drug Codes)
Correct answer: ICD-10-CM
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?
- Verifying patient eligibility before a visit
- Enrolling or disenrolling members in health plans
- Healthcare claim payment and remittance advice (Correct answer)
- Submitting professional claims to health plans
Correct answer: Healthcare claim payment and remittance advice
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?
- The Centers for Medicare & Medicaid Services (CMS)
- The American Medical Association (AMA)
- The Office of the National Coordinator for Health IT (ONC)
- Accredited Standards Committee X12 (ASC X12) (Correct answer)
Correct answer: Accredited Standards Committee X12 (ASC X12)
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?
- X12 271 (eligibility and benefit response) (Correct answer)
- X12 835 (remittance advice)
- X12 277 (claim status response)
- X12 999 (functional acknowledgment only)
Correct answer: X12 271 (eligibility and benefit response)
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.
Question 6: Under HIPAA, a healthcare clearinghouse serves what primary function in the context of electronic transaction standards?
- It stores patient medical records on behalf of covered entities
- It translates non-standard electronic transactions into HIPAA-standard formats, and vice versa (Correct answer)
- It approves all electronic claims before they are submitted to payers
- It enforces HIPAA transaction compliance on behalf of HHS
Correct answer: It translates non-standard electronic transactions into HIPAA-standard formats, and vice versa
A HIPAA clearinghouse is a business that processes or facilitates the processing of health information by translating non-standard formats into HIPAA-compliant standard transactions (or vice versa). Clearinghouses do not store records as a primary function, do not have claims-approval authority, and are not enforcement bodies.
HIPAA Transaction Standards and Code Sets
Which standard electronic transaction format is required under HIPAA for submitting healthcare claims from providers to health plans?