CMS Regulations & Guidance: Health Care Claims Status
Guidance for health care claims status transaction.
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 status.
A health care claim status transaction is used for:
- An inquiry from a provider to a health plan to determine the status of a health care claim
- A response from the health plan to a provider about the status of a health care claim
HIPAA Adopted Standards
In January 2009, HHS adopted Version 5010 of the ASC X12N 276/277 for health care claim status. For more information, see the official ASC X12N website.
This standard applies to all HIPAA-covered entities, health plans, health care clearinghouses, and certain health care providers, not just those who work with Medicare or Medicaid.
Operating Rules
As of January 1, 2013, HIPAA-covered entities are required to comply with federally mandated operating rules for eligibility and claims status.
The operating rules streamline the way eligibility/benefits and claim status information is exchanged electronically. For example, health plans must furnish real-time online access to claims status information, making it easier for providers to determine the status of a claim submitted to a health plan.
View the health care claim status operating rules on the CAQH CORE website
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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.