HIPAA Transaction Services

Transaction Standards & Code Sets

In September 2002, CareFirst filed for a one-year extension to the Transactions and Code Sets regulations to ensure a smooth transition to the new code sets and transactions that must be processed. CareFirst became compliant with the regulations on October 16, 2003.

The CareFirst Companion Guide, to be used in conjunction with the HIPAA Implementation Guides, explains the procedures necessary for our trading partners to conduct Electronic Data Interchange (EDI) transactions. This guide will be expanded and updated as additional standard transactions are ready for testing.

Transaction standards and code sets are used to support the electronic exchange of administrative and financial health care transactions. HIPAA designates "standard" transaction formats that must be used for the following common transactions:

  • Health Care Claims (837)
  • Health Care Payment/Advice (835)
  • Premium Payment/Order Remittance Advice (820)
  • Benefit and Enrollment Maintenance (834)
  • Authorizations and Referrals (278)
  • Inquiry/Response for Eligibility (270/271)
  • Inquiry/Response for Claim Status (276/277)
  • Health Care Claim/Pharmacy NCPDP 5.1

HIPAA has also defined the code sets that will be used to classify member information. The following code sets must be used by the compliance date:

  • Diagnoses and inpatient hospital services: International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM)
  • Institutional Services: ICD-9-CM, Volume 3 and HCFA Common Procedural Coding System (HCPCS)
  • Physician Services: Current Procedural Terminology (CPT)
  • Dental Services: Current Dental Terminology (CDT)
  • Drugs: National Drug Code (NDC)

Questions about HIPAA IT-related regulatory compliance (Transactions, Code Sets, National Identifiers, and Security) can be directed to the Centers for Medicare and Medicaid (CMS) at 410-786-4232 (local) or 1-866-282-0659 (toll-free).

Inquiries regarding set-up, testing and files submissions should be directed to hipaa.partner@carefirst.com.