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Defense Health Agency

"On October 1, 2013, the Department of Defense established the Defense Health Agency (DHA) to manage the activities of the Military Health System. These activities include those previously managed by TRICARE Management Activity (TMA), which was disestablished on the same date. During the next several months, all TMA websites will change to reflect the new DHA. We appreciate your patience during this transition."

Transactions

Background

All health plans, clearinghouses, and providers who choose to submit or receive transactions electronically, are required to use the HIPAA national standards for electronic transactions and to use certain code sets within those transactions. The original Transactions & Code Sets Final Rule, dated August 17, 2000, adopted American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N (Version 4010) and National Council for Prescription Drug Program (NCPDP) (Version 5.1 & 1.1) standards for eight types of administrative transactions.

Current Version

On January 16, 2009, the Department of Health and Human Services (HHS) published the Modifications to HIPAA Electronic Transaction Standards Final Rule which adopted updated versions (X12 Version 5010 and NCPDP Version D.0 and 1.2) of the standards that were adopted in 2000. The 2009 Final Rule also adopted standards to be used for Medicaid Pharmacy Subrogation and billing of retail pharmacy professional services and supplies. The compliance date for use of the updated versions was January 1, 2012.

Type of Transaction

HIPAA Named Transaction

HIPAA Standard including Errata/Addenda1

Health Care Claim

Health Care Claim – Professional (X12 837)

ASC X12N/005010X222, May 2006

ASC X12N/005010X222E1, January 2009

ASC X12N/005010X222A1, June 2010

Health Care Claim – Institutional (X12 837)

ASC X12N/005010X223, May 2006

ASC X12N/005010X223A1, October 2007

ASC X12N/005010X223E1, January 2009

ASC X12N/005010X223A2, June 2010

Health Care Claim – Dental (X12 837)

ASC X12N/005010X224, May 2006

ASC X12N/005010X224A1, October 2007

ASC X12N/005010X224E1, January 2009

ASC X12N/005010X224A2, June 2010

Retail Pharmacy Drugs (NCPDP)

Version D.0, August 2007
(republished August 2010)

Batch Standard Implementation Guide
(Version 1.2)

Retail Pharmacy Supplies and Professional Services (X12 837/ NCPDP)

ASC X12N/005010X223, May 2006

ASC X12N/005010X223A1, October 2007

Version D.0, August 2007
(republished August 2010)

Batch Standard Implementation Guide
(Version 1.2)

Health Care Claims Status

Health Care Claims Status Request & Response (X12 276/277)

ASC X12N/005010X212, August 2006

ASC X12N/005010X212E1, April 2008

ASC X12N/005010X212E2, January 2009

Coordination of Benefits

Coordination of Benefits (X12 837) – Dental

ASC X12N/005010X224, May 2006

ASC X12N/005010X224A1, October 2007

Coordination of Benefits (X12 837) – Professional

ASC X12N/005010X222, May 2006

Coordination of Benefits (X12 837) – Institutional

ASC X12N/005010X223, May 2006

ASC X12N/005010X223A1, October 2007

Retail Pharmacy Drugs (NCPDP)

Version D.0, August 2007
(republished August 2010)

Batch Standard Implementation Guide
(Version 1.2)

Health Plan Premium Payment

Payroll Deducted and Other Group Premium Payment for Insurance Products (X12 820)

ASC X12N/005010X218, February 2007

ASC X12N/005010X218E1, January 2009

Enrollment and Disenrollment in a Health Plan

Benefit Enrollment and Maintenance (X12 834)

ASC X12N/005010X220, August 2006

ASC X12N/005010X220E1, January 2009

ASC X12N/005010X220A1, June 2010

Health Care Payment and Remittance

Health Care Claim Payment/Advice (X12 835)

ASC X12N/005010X221, April 2006

ASC X12N/005010X221A1, June 2010

Eligibility for a Health Plan

Health Care Eligibility Benefit Inquiry and Response (X12 270/271) – Dental, Professional, Institutional

ASC X12N/005010X279, April 2006

ASC X12N/005010X279E1, January 2009

ASC X12N/005010X279A1, June 2010

Eligibility for a Health Plan - Retail Pharmacy Drugs (NCPDP)

Version D.0, August 2007
(republished August 2010)

Batch Standard Implementation Guide
(Version 1.2)

Referral Certification and Authorization

Request for Review & Response (X12 278)

ASC X12N005010X217, May 2006

ASC X12N/005010X217E1, April 2008

Request for Review & Response– Retail Pharmacy Drugs (NCPDP)

Version D.0, August 2007
(republished August 2010)

Batch Standard Implementation Guide
(Version 1.2)

Electronic Funds Transfer (EFT)

National Automated Clearing House Association (NACHA) Corporate Credit or Deposit Entry with Addenda Record (CCD+Addenda) and X12 TRN Segment

2011 NACHA Operating Rules and Guidelines2

and

Content requirements specified in the X12 835 TRN Segment (ASC X12N/005010X221)

Pharmacy Transactions

NCPDP Telecommunication Standard Implementation Guide

Version D.0, August 2007
(republished August 2010)

Medicaid Pharmacy Subrogation

Batch Standard Medicaid Pharmacy Subrogation Implementation Guide

Version 3.0, July 2007

1 Errata/ Addenda: When implementation problems are discovered in an X12 Implementation Guide, errata/addenda are developed. Errata address minor changes that clarify or correct the Implementation Guide, but do not change the transmitted transaction set defined by the Implementation Guide. Addenda contain significant changes to the transmitted transaction set defined by the Implementation Guide.

2 2011 NACHA Operating Rules and Guidelines: The Centers for Medicare and Medicaid Services (CMS) provides the following guidance in FAQ # 6353 on the CMS website (CMS.gov): "The Electronic Payments Association updates its operating rules and guidelines every year with a new version for use by financial institutions. While the implementation specifications in the 2011 NACHA Operating Rules & Guidelines are the adopted standard for the CCD+ Addenda, any version of the NACHA Operating Rules & Guidelines can be used as long as the implementation specifications for the CCD+ Addenda do not differ from those in the 2011 version."

Implementation Guides

For each standard electronic transaction there is an implementation guide which is the specification for implementing the standard.

Click here for a link to obtain the Version 5010 X12 HIPAA Standards /Implementation Guides.

Click here for a link to obtain the NCPDP Versions D.0 and 1.2 Implementation Guides.

Click here for a link to obtain the NACHA Operating Rules and Guidelines.

Maintenance of Transaction Standards

With the publication of the Electronic Transaction and Code Sets Final Rule, the Secretary of HHS announced Designated Standard Maintenance Organizations (DSMOs) to maintain the standards adopted by the Secretary.

Announcement of Designated Standard Maintenance Organizations

* For TRICARE HIPAA Privacy and Security pages, please click here.