HIPAA Compliance Plan
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PART 162 — ADMINISTRATIVE REQUIREMENTS

Subpart A — General Provisions

§ 162.100 Applicability

§ 162.103 Definitions

Code Set Code Set Maintaining Organization Data Condition Data Content Data Element Data Set Descriptor Designated Standard Maintenance Organization (DSMO) Direct Data Entry Format HCPCS Maintain or Maintenance Maximum Defined Data Set Segment Standard Transaction

Subparts B and C — [Reserved]

Subpart D — Standard Unique Health Identifier for Health Care Providers

§ 162.402 Definitions

Covered Health Care Provider

§ 162.404 Compliance dates of the implementation of the standard unique health identifier for health care providers

(a) Health care providers

(b) Health plans

(c) Health care clearinghouses

§ 162.406 Standard unique health identifier for health care providers

(a) Standard

(b) Required and permitted uses for the NPI

§ 162.408 National provider system

§ 162.410 Implementation specifications: Health care providers

§ 162.412 Implementation specifications: Health plans

§ 162.414 Implementation specifications: Health care clearinghouses

Subpart E — [Reserved]

Subpart F — Standard Unique Health Employer Identifier

§ 162.600 Compliance dates of the implementation of the standard unique employer identifier

(a) Health care providers

(b) Health plans

(c) Health care clearinghouses

§ 162.605 Standard unique employer identifier

§ 162.610 Implementation specifications for covered entities

Subparts G and H — [Reserved]

Subpart I — General Provisions for Transactions

§ 162.900 Compliance dates for transaction standards and code sets

(a) Small health plans

(b) Covered entities that timely submitted a compliance plan

(c) Covered entities that did not timely submit a compliance plan

§ 162.910 Maintenance of standards and adoption of modifications and new standards

(a) Designation of DSMOs

(b) Maintenance of standards

(c) Process for modification of existing standards and adoption of new standards

§ 162.915 Trading partner agreements

§ 162.920 Availability of implementation specifications

(a) ASC X12N specifications

(1) The ASC X12N 837- Health Care Claim: Dental

(2) The ASC X12N 837- Health Care Claim: Professional

(3) The ASC X12N 837- Health Care Claim: Institutional

(4) The ASC X12N 835- Health Care Claim Payment/Advice

(5) ASC X12N 834- Benefit Enrollment and Maintenance

(6) The ASC X12N 820- Payroll Deducted and Other Group Premium Payment for Insurance Products

(7) The ASC X12N 278- Health Care Services Review-Request for Review and Response

(8) The ASC X12N 276/277-Health Care Claim Status Request and Response

(9) The ASC X12N 270/271-Health Care Eligibility Benefit Inquiry and Response

(b) Retail pharmacy specifications

(1) The Telecommunication Standard Implementation Guide

(2) The Batch Standard Batch Implementation Guide

(3) The National Council for Prescription Drug Programs (NCPDP) Equivalent NCPDP Batch Standard Batch Implementation Guide

§ 162.923 Requirements for covered entities

(a) General rule

(b) Exception for direct data entry transactions

(c) Use of a business associate

§ 162.925 Additional requirements for health plans

(a) General rules

(b) Coordination of benefits

(c) Code sets

§ 162.930 Additional requirements for health care clearinghouses

§ 162.940 Exceptions from standards to permit testing of proposed modifications

(a) Requests for an exception

(1) Comparison to a current standard

(2) Specifications for the proposed modification

(3) Testing of the proposed modification

(4) Trading partner concurrences

(b) Basis for granting an exception

(c) Secretary's decision on exception

(1) Exception granted

(2) Exception denied

(d) Organization's report on test results

(e) Extension allowed

Subpart J — Code Sets

§ 162.1000 General requirements

(a) Medical data code sets

(b) Nonmedical data code sets

§ 162.1002 Medical data code sets

§ 162.1011 Valid code sets

Subpart K — Health Care Claims or Equivalent Encounter Information

§ 162.1101 Health care claims or equivalent encounter information transaction

§ 162.1102 Standards for health care claims or equivalent encounter information transaction

Subpart L — Eligibility for a Health Plan

§ 162.1201 Eligibility for a health plan transaction

§ 162.1202 Standards for eligibility for a health plan transaction

Subpart M — Referral Certification and Authorization

§ 162.1301 Referral certification and authorization transaction

§ 162.1302 Standards for referral certification and authorization transaction

Subpart N — Health Care Claim Status

§ 162.1401 Health care claim status transaction

§ 162.1402 Standards for health care claim status transaction

Subpart O — Enrollment and Disenrollment in a Health Plan

§ 162.1501 Enrollment and disenrollment in a health plan transaction

§ 162.1502 Standards for enrollment and disenrollment in a health plan transaction

Subpart P — Health Care Payment and Remittance Advice

§ 162.1601 Health care payment and remittance advice transaction

§ 162.1602 Standards for health care payment and remittance advice transaction

Subpart Q — Health Plan Premium Payments

§ 162.1701 Health plan premium payments transaction

§ 162.1702 Standards for health plan premium payments transaction

Subpart R — Coordination of Benefits

§ 162.1801 Coordination of benefits transaction

§ 162.1802 Standards for coordination of benefits information transaction

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