Transaction


The transmission of information between two parties to carry out financial or administrative activities related to health care. [45 CFR 160-­103] 

It includes the following types of information transmissions: 

  1. Health care claims or equivalent encounter information. 
    This transaction may be used to submit health care claim billing information, encounter information, or both, from health care providers to payers, either directly or via intermediary billers and claims clearinghouses. 

  2. Health care payment and remittance advice. 
    This transaction may be used by a health plan to make a payment to a financial institution for a health care provider (sending payment only), to send an explanation of benefits remittance advice directly to a health care provider (sending data only), or to make payment and send an explanation of benefits remittance advice to a health care provider via a financial institution (sending both payment and data). 

  3. Coordination of benefits. 
    This transaction set can be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the furnishing, billing, and/or payment of health care services within a specific health care/insurance industry segment. 

    In addition to the nine electronic transactions specified in section 1173(a)(2) of the Act, section 1173(f) directs the Secretary to adopt standards for transferring standard data elements among health plans for coordination of benefits. This particular provision does not state that these should be standards for electronic transfer of standard data elements among health plans. However, we believe that the Congress, when writing this provision, intended for these standards to be an electronic form of transactions for coordination of benefits and sequential processing of claims. The Congress expressed its intent on these matters generally in section 1173(a)(1)(B)of the Act, where the Secretary is directed to adopt "other financial and administrative transactions ... consistent with the goals of improving the operation of the health care system and reducing administrative costs." 

  4. Health care claim status. 
    This transaction may be used by health care providers and recipients of health care products or services (or their authorized agents) to request the status of a health care claim or encounter from a health plan. 

  5. Enrollment and disenrollment in a health plan. 
    This transaction may be used to establish communication between the sponsor of a health benefit and the payer. It provides enrollment data, such as subscriber and dependents, employer information, and primary care health care provider information. A sponsor is the backer of the coverage, benefit, or product. A sponsor can be an employer, union, government agency, association, or insurance company. The health plan refers to an entity that pays claims, administers the insurance product or benefit, or both. 

  6. Eligibility for a health plan. 
    This transaction may be used to inquire about the eligibility, coverage, or benefits associated with a benefit plan, employer, plan sponsor, subscriber, or a dependent under the subscriber’s policy. It also can be used to communicate information about or changes to eligibility, coverage, or benefits from information sources (such as insurers, sponsors, and payers) to information receivers (such as physicians, hospitals, third party administrators, and government agencies). 

  7. Health plan premium payments. 
    This transaction may be used by, for example, employers, employees, unions, and associations to make and keep track of payments of health plan premiums to their health insurers. This transaction may also be used by a health care provider, acting as liaison for the beneficiary, to make payment to a health insurer for coinsurance, copayments, and deductibles. 

  8. Referral certification and authorization. 
    This transaction may be used to transmit health care service referral information between health care providers, health care providers furnishing services, and payers. It can also be used to obtain authorization for certain health care services from a health plan. 

  9. First report of injury. 
    This transaction may be used to report information pertaining to an injury, illness, or incident to entities interested in the information for statistical, legal, claims, and risk management processing requirements. 

  10. Health claims attachments. 
    This transaction may be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis, or treatment data for the purpose of a request for review, certification, notification, or reporting the outcome of a health care services review. 

  11. Other transactions that the Secretary may prescribe by regulation. 
    Under section 1173(a)(1)(B) of the Act, the Secretary may adopt standards, and data elements for those standards, and for other financial and administrative transactions deemed appropriate by the Secretary. These transactions would be consistent with the goals of improving the operation of the health care system and reducing administrative costs.
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