Centers for Medicare & Medicaid Services Adopted Standards and Operating Rules
HIPAA required HHS (Department of Health & Human Services) to establish national standards for electronic transactions to improve the efficiency and effectiveness of the nation’s health care system.
These standards apply to all HIPAA covered entities:
- Health plans
- Health care clearinghouses
- Health care providers who conduct electronic transactions, not just those who accept Medicare or Medicaid
Any provider who accepts payment from any health plan or other insurance company must comply with HIPAA if they conduct the adopted transactions electronically.
These providers must also have written agreements in place to ensure business associates comply with HIPAA. Examples of business associates include clearinghouses and independent medical transcriptionists.
Adopted standards for electronic health care transactions
- ASC X12 Version 5010 is the adopted standard format for transactions, except those with retail pharmacies.
- For retail pharmacy transactions, HHS adopted two standards from the National Council for Prescription Drug Programs (NCPDP):
- Pharmacy and supplier transactions – NCPDP Version D.0
- Medicaid subrogation – NCPDP Version 3.0
Operating Rules
Operating rules, which are required by the Patient Protection and Affordable Care Act, are defined as “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.”
Operating rules set certain requirements for transactions that are covered by HIPAA. They specify the information that must be included when conducting standard transactions, making it easier for providers to use electronic means to handle administrative transactions. CAQH CORE is the authoring entity of the operating rules currently adopted by HHS.
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