Final

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

Issue Date: August 02, 2020

Under HIPAA, HHS adopted standards for electronic transactions, including for referral certification and authorization.

The referral certification and authorization transaction is any of the following:

• A request from a health care provider to a health plan to obtain an authorization of health care
• A request from a health care provider to a health plan to obtain authorization for referring an individual to another health care provider
• A response from a health plan to a health care provider about authorization and referral requests

HIPAA Adopted Standards

In January 2009, HHS adopted Version 5010 of the ASC X12N 278 for referral certification and authorization. For more information, see the official ASC X12N website.

For pharmacy-related referral certifications and authorizations, 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.

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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.