The final rule for Transactions and Code Sets, published in the Federal Register August 17, 2000,
establishes standards for electronic transactions and external medical data code sets as illustrated
in the following tables.
|
Transactions |
| Transaction Type |
Standard |
|
Claim or Equivalent Encounter Information - Professional |
ASC X12N 837 - Health Care Claim: Professional, Version 4010, May 2000 |
|
Claim or Equivalent Encounter Information - Institutional |
ASC X12N 837 - Health Care Claim: Institutional, Version 4010, May 2000 |
|
Claim or Equivalent Encounter Information - Dental |
ASC X12N 837 - Health Care Claim: Dental, Version 4010, May 2000 |
|
Claim or Equivalent Encounter Information - Retail Pharmacy |
NCPDP Telecommunications Standard Format, Version 5.1 September 1999
NCPDP Batch Standard Format, Version 1.0 February 1, 1996 |
|
Remittance Advice |
ASC X12N 835 - Health Care Claim Payment/Advice, Version 4010, May 2000 |
|
Claim Status and Response |
ASC X12N 276/277 - Health Care Claim Status Request and Response, Version 4010, May 2000 |
|
Eligibility Inquiry and Response |
ASC X12N 270/271 - Health Care Eligibility Benefit Inquiry and Response, Version 4010, May 2000 |
|
Enrollment and Maintenance |
ASC X12N 834 - Benefit Enrollment and Maintenance, Version 4010, May 2000 |
|
Requests for Review and Response |
ASC X12N 278 - Health Care Services Review - Request for Review and Response, Version 4010, May 2000 |
|
Premium Payment for Insurance Products |
ASC X12N 820 - Payroll Deducted and Other Group Premium Payment for Insurance Products, Version 4010, May 2000 |
Code Sets |
| Medical Data Code Set |
Purpose |
|
International Classification of Diseases, ICD-9-CM, Volumes 1 and 2 |
Diagnoses |
|
International Classification of Diseases, ICD-9-CM, Volume 3 Procedures |
Procedures, Inpatient |
|
National Drug Codes (NDC) |
Drugs and Biologics |
|
Code on Dental Procedures and Nomenclature |
Dental Services |
|
Health Care Financing Administration Common Procedure Coding System (HCPCS) and Current Procedural Terminology, Fourth Edition (CPT-4) |
Physician and Other Health Services |
|
Health Care Financing Administration Common Procedure Coding System (HCPCS) |
All Other Substances, Supplies, Equipment, or Other Items Used in Health Care Services |