HIPAA

Health Insurance Portability and Accountability Act. The 1996 US law that made X12 version 5010 the mandated standard for electronic healthcare exchanges.

Definition

HIPAA is a US federal law enacted in 1996 (Public Law 104-191) whose Title II "Administrative Simplification" imposes uniform rules for the electronic exchange of healthcare data between payers (insurers), providers (physicians, hospitals) and related entities. The US Department of Health and Human Services (HHS) is its enforcement authority.

For EDI, HIPAA mandates the use of ANSI ASC X12 version 5010 for the following transactions:

1. 270 / 271 — eligibility and benefit inquiry and response.
2. 276 / 277 — claim status inquiry and response.
3. 278 — services review and prior authorisation request.
4. 820 — payroll deducted and other group premium payment for insurance products.
5. 834 — benefit enrollment and maintenance.
6. 835 — health care claim payment and remittance advice.
7. 837 — health care claim (Professional, Institutional, Dental).

Origin

The 5010 mandate rule was notified by HHS in 2009. Its effective date was set to 1 January 2012, after several delays driven by the migration complexity from the historically used 4010A1. As of 2026, 5010 remains the only X12 version admissible for HIPAA transactions.

Example in context

A medical practice files a claim with a US private insurer. Its billing system generates an X12 837P (Professional) transaction in 5010A1, sends it through a HIPAA-certified clearinghouse, and receives in return: 999 (Implementation Acknowledgment), 277CA (Claims Acknowledgment), then 835 (Remittance Advice) once the claim is adjudicated.

Related terms

• X12 — the standard HIPAA relies on.
• X12 versions — page detailing the 5010 version mandated by HIPAA.
• EDI — the overarching discipline.
• CONTRL — EDIFACT equivalent of 997/999 used in HIPAA.