Frequently Asked Questions About Electronic Transaction Standards Adopted Under HIPAA. Should health plans publish companion documents that augment the information in the standard implementation guides for electronic transactions?


Additional information may be provided within certain limits.

Electronic transactions must go through two levels of scrutiny:

  1. Compliance with the HIPAA standard. The requirements for compliance must be completely described in the HIPAA implementation guides and may not be modified by the health plans or by the health care providers using the particular transaction.
  2. Specific processing or adjudication by the particular system reading or writing the standard transaction. Specific processing systems will vary from health plan to health plan, and additional information regarding the processing or adjudication policies of a particular health plan may be helpful to providers.

Such additional information may not be used to modify the standard and may not include:

  • Instructions to modify the definition, condition, or use of a data element or segment in the HIPAA standard implementation guide.
  • Requests for data elements or segments that are not stipulated in the HIPAA standard implementation guide.
  • Requests for codes or data values that are not valid based on the HIPAA standard implementation guide. Such codes or values could be invalid because they are marked not used in the implementation guide or because they are simply not mentioned in the guide.
  • Change the meaning or intent of a HIPAA standard implementation guide.