The health care claims or equivalent encounter information transaction is the transmission of either of the following:
(a) A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care.
(b) If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care.
§ 162.1011: Valid code sets
§ 162.1102: Standards for health care claims or equivalent encounter information transaction