HIPAA Transaction Standards and Code Sets Flashcards
6 cards from real HIPAA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 HIPAA Transaction Standards and Code Sets flashcards as text
Which standard electronic transaction format is required under HIPAA for submitting healthcare claims from providers to health plans?
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.
Under HIPAA Administrative Simplification, which code set is mandated for reporting diagnoses on inpatient hospital claims?
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.
The X12 835 transaction under HIPAA is used for which purpose?
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.
Which organization develops and maintains the ASC X12 transaction standards that HIPAA requires for most electronic healthcare transactions?
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.
A health plan receives an X12 270 transaction from a provider. What transaction is the health plan required to send in response?
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.
Under HIPAA, a healthcare clearinghouse serves what primary function in the context of electronic transaction standards?
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.