HIPAA Standards for Electronic Transactions

Eprosystem HIPAA standard ANSI 837 4010A1 Compliant

Effective October 1st, 2005, Centers for Medicare and Medicaid Services (CMS) ends the contingency plan for incoming non-HIPAA compliant Medicare claims. All professional claims submitted electronically to CMS will have to be submitted in the HIPAA standard ANSI 837 4010A1 format or will be rejected. HIPAA applies not only to Medicare and Medicaid claims but also to commercial insurances, such as Blue Cross Blue Shield plans and other payors.

The HIPAA standard format contains certain required data elements not currently carried on the traditional HCFA 1500 and UB-92 forms including such elements as:

    • A payer responsibility sequence code (i.e., identifies the insurance carrier’s level of responsibility—primary, secondary, etc.)
    • A taxonomy/specialty code if the rendering provider is the same entity as the billing provider
    • A greatly expanded section requiring a more specific designation of relationships between the patient and the insured


Eprosystem has been proactively monitoring the HIPAA standards for electronic transactions for some time and has implemented system modifications to ensure a smooth adaptation of the ANSI 837 4010A1 standard. In spite of the immense scope and initial resource requirements for compliance initiatives, the benefits will be very significant! After these standards have been put in place, you will be able to submit data for claims and other standardized transactions using a system that conforms to industry EDI standards. All Health Plans are required to accept and process these transactions without imposing delays because of format or content.

HIPAA standardizing transactions will make electronic data interchange the preferred method of doing business over current processing methods. Ultimately, HIPAA and Eprosystem are poised to create a dramatic improvement in the efficiency and effectiveness of your organization.