Transaction and Code Sets

General Requirements.
A health care component within the University of North Texas that uses electronic media for any transaction covered under 45 CFR §162.1002 must conduct the transaction using the code sets specified by the Department of Health and Human Services.

A health care component electing to use direct data entry offered by a health plan to conduct a transaction for which a standard has been adopted by the Department of Health and Human Services must use the applicable data content and data condition requirements of the standard when conducting the transaction. The health care component is not required to use the format requirements of the standard.

A health care component may use a business associate, including a health care clearinghouse, to conduct a transaction. In such a case, the health care component must require the business associate to do the following:

            (1) Comply with all applicable transaction and code set requirements.

            (2) Require any agent or subcontractor to comply with all applicable requirements of the Department of Health and Human Services regulations.

Code Sets
When conducting a transaction, a health care component must use the applicable medical data code sets as specified in the implementation specification adopted by the Department of Health and Human Services and that are valid at the time the health care is furnished. The provider must also use the applicable nonmedical data code sets that are valid at the time the transaction is initiated.

Standards
The Department of Health and Human Services has adopted the following standards for the coordination of benefits information transaction:

      (a) Retail pharmacy drug claims. The NCPDP Telecommunication Standard Implementation Guide, Version 5 Release 1, September 1999, and equivalent NCPDP Batch Standard Batch Implementation Guide, Version 1 Release 0, February 1, 1996.

      (b) Professional health care claims. The ASC X12N 837 - Health Care Claim: Professional, Volumes 1 and 2, Version 4010, May 2000, Washington Publishing Company, 004010X098. The implementation specification is available at the addresses specified in §162.920(a)(1).

Compliance Date
The date for complying with the Transaction and Code Set Regulations of the Department of Health and Human Services is October 16, 2003. Health care components that are not required to file claims electronically by that date must comply with this policy when they begin filing claims electronically, or when the entity with which they are filing claims requires electronic claim filings, whichever comes first.