HIPAA Compliance Guide

HIPAA Overview & Regulations

HIPAA Compliance Guide
What is HIPAA? What is a HIPAA BAA?
Regulations
General Administrative Requirements
Subpart A
General Provisions
Subpart B
Preemption Of State Law
Subpart C
Compliance and Investigations
Subpart D
Imposition of Civil Money Penalties
Subpart E
Procedures for Hearings
Administrative Requirements
Subpart A
General Provisions
Subpart D
Standard Unique Health Identifier For Health Care Providers
Subpart E
Standard Unique Health Identifier For Health Plans
Subpart F
Standard Unique Employer Identifier
Subpart I
General Provisions For Transactions
Subpart J
Code Sets
Subpart K
Health Care Claims Or Equivalent Encounter Information
Subpart L
Eligibility For A Health Plan
Subpart M
Referral Certification And Authorization
Subpart N
Health Care Claim Status
Subpart O
Enrollment And Disenrollment In A Health Plan
Subpart P
Health Care Electronic Funds Transfers (EFT) And Remittance Advice
Subpart Q
Health Plan Premium Payments
Subpart R
Coordination Of Benefits
Subpart S
Medicaid Pharmacy Subrogation
Security and Privacy
Subpart A
General Provisions
Subpart C
Security Standards For The Protection Of Electronic Protected Health Information
Subpart D
Notification In The Case Of Breach Of Unsecured Protected Health Information
Subpart E
Privacy Of Individually Identifiable Health Information

Administrative Requirements   >   Referral Certification And Authorization

§ 162.1302 Standards for referral certification and authorization transaction

The Secretary adopts the following standards for the referral certification and authorization transaction:

(a) For the period from October 16, 2003 through March 16, 2009:

(1) Retail pharmacy drug referral certification and authorization. The NCPDP Telecommunication Standard Implementation Guide, Version 5, Release 1 (Version 5.1), September 1999, and equivalent NCPDP Batch Standard Batch Implementation Guide, Version 1, Release 1 (Version 1.1), January 2000, supporting Telecommunications Standard Implementation Guide, Version 5, Release 1 (Version 5.1) for the NCPDP Data Record in the Detail Data Record. (Incorporated by reference in § 162.920).

(2) Dental, professional, and institutional referral certification and authorization. The ASC X12N 278–Health Care Services Review–Request for Review and Response, Version 4010, May 2000, Washington Publishing Company, 004010X094 and Addenda to Health Care Services Review–Request for Review and Response, Version 4010, October 2002, Washington Publishing Company, 004010X094A1. (Incorporated by reference in § 162.920).

(b) For the period from March 17, 2009 through December 31, 2011 both–

(1) The standards identified in paragraph (a) of this section; and

(2)

(i) Retail pharmacy drugs. The Telecommunication Standard Implementation Guide Version D, Release 0 (Version D.0), August 2007, and equivalent Batch Standard Implementation Guide, Version 1, Release 2 (Version 1.2), National Council for Prescription Drug Programs. (Incorporated by reference in § 162.920.)

(ii) Dental, professional, and institutional request for review and response. The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3–Health Care Services Review–Request for Review and Response (278), May 2006, ASC X12N/005010X217, and Errata to Health Care Services Review—Request for Review and Response (278), ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, April 2008, ASC X12N/005010X217E1. (Incorporated by reference in § 162.920.)

(c) For the period on and after January 1, 2012, the standards identified in paragraph (b)(2) of this section.

[68 FR 8398, Feb. 20, 2003, as amended at 74 FR 3326, Jan. 16, 2009]

HIPAA Regulations

§ 162.1301: Referral certification and authorization transaction

HIPAA Regulations

§ 162.1401: Health care claim status transaction