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Health Care Claim or Equivalent Encounter Information

Guidance for the health care claims or equivalent encounter information transaction.

Final

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: August 02, 2020

Under HIPAA, HHS adopted standards for electronic transactions, including for health care claim or equivalent encounter information.

The health care claims or equivalent encounter information transaction includes either of the following:

  • A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care
  • The transmission of encounter information for the purpose of reporting health care, if there is no direct claim

HIPAA Adopted Standards

In January 2009, HHS adopted Version 5010 of the ASC X12N 837 for health care claim or equivalent encounter information. For more information, see the official ASC X12N website.

For pharmacy claims, HHS adopted National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard Version D.0. 

These standards apply to all HIPAA covered entities, health plans, health care clearinghouses, and certain health care providers, not just those who work with Medicare or Medicaid.

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.