各医療サービス提供者 (病院、医師など)、医療保険プロバイダー（保険会社など) およびその他の医療情報センターは、医療関連データの交換を HIPAA に定められた電子フォーマットに従って行う必要があります。
HIPAA 法の発効後、HIPAA フォーマットに準拠していない医療料金や保険請求は受付られなくなっています。
|
トランザクション名
|
番号
|
用途
|
| Claim/encounter |
X12 837 |
For submitting claim to health plan, insurer, or other payer
|
Eligibility inquiry and
response |
X12 270
and 271 |
For inquiring of a health plan the status of a patient’s eligibility for benefits and details regarding the types of services covered, and for receiving information in response from the health plan or payer.
|
Claim status inquiry and
response
|
X12 276
and 277 |
For inquiring about and monitoring outstanding claims (where is the claim? Why haven’t you paid us?) and for receiving information in response from the health plan or payer. Claims status codes are now standardized for all payers.
|
Referrals and prior
authorizations
|
X12 278 |
For obtaining referrals and authorizations accurately and quickly, and for receiving prior authorization responses from the payer or utilization management organization ( UMO ) used by a payer.
|
| Health care payment and remittance advice |
X12 835 |
For replacing paper EOB/EOPs and explaining all adjustment data from payers.
Also, permits auto-posting of payments to accounts receivable system.
|
| Health claims attachments (proposed) |
X12 275 |
For sending detailed clinical information in support of claims, in response to payment denials, and other similar uses.
|
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