| A/P Update File |
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File used to update payer payment numbers when consolidation eliminates original.
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| Accredited Standards Committee (ASC) |
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An organization that has been accredited by ANSI for the development of American National Standards.
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| Administrative Simplification (A/S) |
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Title II, Subtitle F, of HIPAA, which gives DHHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information.
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| American Dental Association (ADA) |
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A professional organization for dentists. The ADA maintains the hardcopy dental claim form and the associated claim submission specifications, and also maintains the Current Dental Terminology (CDTä) code set. The ADA has a formal consultative role under HIPAA, and hosts the Dental Content Committee.
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| American Hospital Association (AHA) |
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A health care industry association that represents the concerns of institutional providers. The AHA hosts the NUBC, which has a formal consultative role under HIPAA.
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| American Medical Association (AMA) |
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A professional organization for physicians. The AMA is the secretariat of the NUCC, which has a formal consultative role under HIPAA. The AMA also maintains the Current Procedural Terminology (CPT) code set.
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American National Standards (ANS)
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Standards developed and approved by organizations accredited by ANSI. |
| American National Standards Institute (ANSI) |
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An organization that accredits various standards-setting committees, and monitors their compliance with the open rule-making process that they must follow to qualify for ANSI accreditation.
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| American Society for Testing and Materials (ASTM) |
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A standards group that has published general guidelines for the development of standards, including those for health care identifiers. ASTM Committee E31 on Healthcare Informatics develops standards on information used within healthcare.
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Association for Electronic Health Care Transactions (AFEHCT)
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An organization that promotes the use of EDI in the health care industry. |
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| Centers for Disease Control and Prevention (CDC) |
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An organization that maintains several code sets included in the HIPAA standards, including the ICD-9-CM codes.
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| Claim Adjustment Reason Codes |
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A national code set for indicating the reasons for any differences, or adjustments, between the original provider charge for a claim or service and the current payment for it. This code set is used in the X12 835 Claim Payment & Remittance Advice and the X12 837 Claim EDI transactions, and is maintained by the Health Care Code Maintenance Committee.
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| Claim Attachment |
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Any of a variety of hardcopy forms or electronic records needed to process a claim in addition to the claim itself.
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Claim Medicare Remarks Codes
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See Medicare Remittance Advice Remark Codes. |
| Claim Status Category Codes |
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A national code set for indicating the general category of the status of health care claims. This codeset is used in the X12 277 Claim Status Notification EDI transactions, and is maintained the Health Care Code Maintenance Committee.
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| Claim Status Codes |
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A national code set for indicating the status of health care claims. This code set is used in the X12 277 Claim Status Notification EDI transactions, and is maintained by the Health Care Code Maintenance Committee.
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| Clearinghouse (or Health Care Clearinghouse) |
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For health care, an organization that translates health care data to or from a standard format.
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| Computer-based Patient Record Institute (CPRI) |
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An industry organization that promotes the use of electronic healthcare records.
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| Coordination of Benefits (COB) |
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A process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim. Also called crossover.
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| Current Dental Terminology (CDT) |
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A dental procedure code set maintained by the ADA, and that has been selected for use in the HIPAA transactions.
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| Current Procedural Terminology (CPT) |
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A procedure code set maintained and copyrighted by the AMA, and that has been selected for use under HIPAA for non-institutional and non-dental professional transactions.
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| Data Council |
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A coordinating body within the DHHS that has high-level responsibility for overseeing the implementation of the A/S provisions of HIPAA.
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| Data Interchange Standards Association (DISA) |
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A body that provides administrative services to X12 and several other standards-related groups.
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| Data Mapping |
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The process of matching one set of data elements or individual code values to their closest equivalents in another set of them.
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| Dental Content Committee |
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An organization, hosted by the American Dental Association, which maintains the data element specifications for dental billing. The ADA has a formal consultative role under HIPAA for all transactions affecting dental health care services.
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| Department of Health and Human Services (DHHS) |
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The Federal Government Department that has overall responsibility for implementing HIPAA. |
| Designated Standard |
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A standard, which DHHS has designated for use under the authority provided by HIPAA.
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Digital Imaging and Communications in Medicine (DICOM)
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A standard for communicating images, such as x-rays, in a digitized form. It could be included in the claim attachments standards. |
| DISA |
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The Data Interchange Standards Association.
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EBFM - Electronic Business Flow Management
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A form of procedural and control for deployment of HIPAA transactions. |
| EDI |
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Electronic Data Interchange
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| EDIA |
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Electronic Data Interchange for Administration
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| EDIFACT |
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Electronic Data Interchange for Administration, Commerce, and Transport
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| EFT |
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Electronic Funds Transfer
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| Electronic Commerce (EC) |
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The exchange of business information by electronic means.
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| Electronic Data Interchange (EDI) |
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This usually means X12 and similar variable-length formats for the electronic exchange of structured data. It is sometimes used more broadly to mean any electronic exchange of formatted data.
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Electronic Healthcare Network Accreditation Commission (EHNAC)
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An organization that accredits healthcare clearinghouses. |
| Electronic Remittance Advice (ERA) |
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Any of several electronic formats for explaining the payments of health care claims.
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| EOR |
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Explanation of Review (Terminology used in Workers' Compensation)
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| Flat File |
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This term usually refers to a file that consists of a series of fixed-length records that include some sort of record type code.
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| HCFA Common Procedural Coding System (HCPCS) |
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A medical code set that identifies health care procedures, equipment, and supplies for claim submission purposes. It is maintained by HCFA, and has been selected for use in the HIPAA transactions.
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| Health Care Code Maintenance Committee |
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An organization administered by the BCBSA that is responsible for maintaining certain coding schemes used in theX12 transactions. These include the Claim Adjustment Group Codes, the Claim Adjustment Reason Codes, the Claim Status Category Codes, and the Claim Status Codes.
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| Health Care Financing Administration (HCFA) |
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The DHHS agency responsible for Medicare and parts of Medicaid. HCFA has historically maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, as well as specifications for various certifications and authorizations used by the Medicare and Medicaid programs.HCFA also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes.
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| Health Care Provider Taxonomy Committee |
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An organization administered by the BCBSA that is responsible for maintaining the Provider Taxonomy coding scheme used in the X12 transactions. The detailed code maintenance is done under the guidance of X12N/TG2/WG15.
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Health Industry Business Communications Council (HIBCC)
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A council of health care industry associations which has developed a number of technical standards used within the healthcare industry. |
| Health Informatics Standards Board (HISB) |
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A standards group that has developed an inventory of candidate standards for consideration as possible HIPAA standards.
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| Health Insurance Association of America (HIAA) |
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An industry association that represents the interests of commercial health care insurers. The HIAA participates in the maintenance of some code sets, including HCPCS Level II codes.
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| Health Insurance Portability and Accountability Act of1996 (HIPAA) |
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A Federal law that makes a number of changes which have the goal of allowing persons to qualify immediately for comparable health insurance coverage when they change their employment relationships.Title II, Subtitle F, of HIPAA gives DHHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. Also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104-191.
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| Health Level Seven (HL7) |
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An ANSI-accredited group that defines standards for the cross-platform exchange of information within a health care organization.HL7 is responsible for specifying the Level Seven OSI standards for the health industry. Some HL7 standards will be encapsulated in the X12 standards used for transmitting claim attachments. The HL7 Claims Attachment SIG (CA-SIG) is responsible for the HL7 portion of this standard.
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| Healthcare Financial Management Association (HFMA) |
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An organization for the improvement of the financial management of healthcare-related organizations. The HFMA sponsors some HIPAA educational seminars.
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| HIAA |
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The Health Insurance Association of America
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| HIPAA Data Dictionary or HIPAA DD |
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A data dictionary that defines and cross-references the contents of all X12 transactions included in the HIPAA mandate. It is maintained by X12N/TG3.
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| Implementation Guide (IG) |
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A document explaining the proper use of a standard for a specific business purpose. The X12N HIPAA IG’s are the primary reference documents used by those implementing the associated transactions, and are incorporated into the HIPAA regulations by reference.
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| International Standards Organization (ISO) or International Organization for Standardization |
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A medical code set maintained by the World Health Organization (WHO). The primary purpose of this code set is to classify causes of death. A US extension of this coding system, maintained by the NCHS within the CDC, is used to identify morbidity factors, or diagnoses. The ICD-9-CM codes have been selected for use in the HIPAA transactions.
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| ISO |
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An organization that coordinates the development and adoption of numerous international standards.
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| Joint Commission on Accreditation of Healthcare Organizations(JCAHO) |
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An organization that accredits healthcare organizations. In the future, the JCAHO may play a role in certifying these organizations compliance with<br>the HIPAA A/S requirements.
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| Medicare Remittance Advice Remark Codes |
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A national code set for providing either claim-level or service-level Medicare-related messages that cannot be expressed with a Claim Adjustment Reason Code. This code set is used in the X12 835 Claim Payment & Remittance Advice EDI transactions, and is maintained by the HCFA.
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| Memorandum of Understanding (MOU) |
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A document providing a general description of the kinds of responsibilities that are to be assumed by two or more parties in their pursuit of some goal(s). More specific information may be provided in an associated SOW.
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National Association of Insurance Commissioners (NAIC)
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An association of the insurance commissioners of the states and territories. |
| National Association of State Medicaid Directors (NASMD) |
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An association of state Medicaid directors. NASMD is affiliated with the American Public Health Human Services Association (APHSA).
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| National Center for Health Statistics (NCHS) |
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A federal organization within the CDC that collects, analyzes, and distributes health care statistics. The NCHS maintains the ICD-x-CM codes.
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| National Committee for Quality Assurance (NCQA) |
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An organization that accredits managed care plans or Health Maintenance Organizations (HMOs). In the future, the NCQA may play a role in certifying these organizations’ compliance with the HIPAA A/S requirements.
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| National Committee on Vital and Health Statistics (NCVHS) |
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A Federal body within the DHHS, which has an important advisory role under HIPAA.
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| National Council for Prescription Drug Programs (NCPDP) |
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An ANSI-accredited group that maintains a number of standard formats for use by the retail pharmacy industry, some of which are included in the HIPAA mandates.
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| National Drug Code (NDC) |
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A medical code set that identifies prescription drugs and some over the counter products, and that has been selected for use in the HIPAA transactions.
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| National Health Information Infrastructure (NHHI) |
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This is a healthcare-specific lane on the Information Superhighway, as described in the National Information Infrastructure (NII) initiative. Conceptually, this includes the HIPAA A/S initiatives.
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| National Payer ID |
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A system for uniquely identifying all organizations which pay for health care services. Also known as Health Plan ID, or Plan ID.
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| National Provider ID (NPI) |
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A system for uniquely identifying all providers of health care services, supplies, and equipment.
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| National Uniform Billing Committee (NUBC) |
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An organization, chaired and hosted by the American Hospital Association, that maintains the UB-92 hardcopy institutional billing form and the data element specifications for both the hardcopy form and the 192-byte UB-92 flat file EMC format. The NUBC has a formal consultative role under HIPAA for all transactions affecting institutional health care services.
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| National Uniform Claim Committee (NUCC) |
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An organization, chaired and hosted by the American Medical Association, that maintains the HCFA-1500 claim form and a set of data element specifications for professional claims submission via the HCFA 1500 claim form, the Professional EMC NSF, and the X12 837. The NUCC has a formal consultative role under HIPAA for all transactions affecting non-dental, non-institutional professional health care services.
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| PRA |
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Provider Remittance Advice
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| Provider Taxonomy Codes |
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A code set for identifying the provider type and area of specialization for all health care providers. <br>A given provider can have several Provider Taxonomy Codes. This code set is used <br>in the X12 278 Referrals and Authorization and the X12 837 Claim EDI transactions, <br>and is maintained by the Health Care Provider Taxonomy Committee.
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| UAT |
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User Acceptance Testing
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| Uniform Claim Task Force (UCTF) |
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An organization that developed the initial HCFA-1500 Professional Claim Form. The maintenance responsibilities were later assumed by the NUCC.
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| Value-Added Network (VAN) |
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A vendor of EDI data communications and translation services.
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| Washington Publishing Company (WPC) |
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A company that publishes the X12N HIPAA Implementation Guides and the X12N HIPAA Data Dictionary, and that also developed the X12 Data Dictionary.
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| Workgroup for Electronic Data Interchange (WEDI) |
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A health care industry group that lobbied for HIPAA A/S, and that has a formal consultative role under the HIPAA legislation.
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| X12 |
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An ANSI-accredited group that defines EDI standards for many American industries, including health care insurance. Most of the electronic transaction standards proposed under HIPAA are X12 standards.
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| X12 148 |
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X12’s First Report of Injury, Illness, or Incident EDI transaction.
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| X12 270 |
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X12’s Health Care Eligibility & Benefit Inquiry EDI transaction.
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| X12 271 |
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X12’s Health Care Eligibility & Benefit Response EDI transaction.
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| X12 274 |
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X12’s Provider Information EDI transaction.
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| X12 275 |
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X12’s Patient Information EDI transaction.
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| X12 276 |
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X12’s Health Care Claims Status Inquiry EDI transaction.
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| X12 277 |
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X12’s Health Care Claim Status Response EDI transaction.
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| X12 278 |
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X12’s Referral Certification and Authorization EDI transaction.
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| X12 811 |
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X12’s Consolidated Service Invoice & Statement EDI transaction.
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| X12 820 |
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X12’s Payment Order & Remittance Advice EDI transaction.
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| X12 831 |
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X12’s Application Control Totals EDI transaction.
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| X12 834 |
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X12’s Benefit Enrollment & Maintenance EDI transaction.
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| X12 835 |
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X12’s Health Care Claim Payment & Remittance Advice EDI transaction. |
| X12 837d |
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X12’s Dental Health Care Claim or Encounter EDI transaction.
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| X12 837i |
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X12’s Institutional Health Care Claim or Encounter EDI transaction.
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| X12 837p |
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X12’s Professional Health Care Claim or Encounter EDI transaction.
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| X12 997 |
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X12’s Functional Acknowledgement EDI transaction.
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| X12F |
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A subcommittee of X12 that defines EDI standards for the financial industry. This group maintains the X12 811 [generic]Invoice and the X12 820[generic] Payment & Remittance Advice transactions, although X12N maintains the associated HIPAA Implementation Guides.
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| X12J |
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A subcommittee of X12 that reviews X12 work products for compliance with the X12 design rules.
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| X12N |
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A subcommittee of X12 that defines EDI standards for the insurance industry, including health care insurance.
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| X12N/SPTG4 |
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The HIPAA Liaison Special Task Group of the Insurance Subcommittee (N) of X12. This group’s responsibilities have been assumed by X12N/TG3/WG3.
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| X12N/TG1 |
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The Property & Casualty Task Group (TG1) of the Insurance Subcommittee (N) of X12.
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| X12N/TG2 |
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The Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12.
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| X12N/TG2/WG1 |
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The Health Care Eligibility Work Group (WG1) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 270 Health Care Eligibility & Benefit Inquiry and the X12 271 Health Care Eligibility & Benefit Response EDI transactions.
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| X12N/TG2/WG10 |
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The Health Care Services Review Work Group (WG10) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 278 Referral Certification and Authorization EDI transaction.
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| X12N/TG2/WG12 |
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The Interactive Health Care Claims Work Group (WG12) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the IHCCLM EDI transaction.
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| X12N/TG2/WG15 |
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The Health Care Provider Information Work Group (WG15) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 274 Provider Information EDI transaction.
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| X12N/TG2/WG19 |
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The Health Care Implementation Coordination Work Group (WG19) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This is now X12N/TG3/WG3.
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| X12N/TG2/WG2 |
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The Health Care Claims Work Group (WG2) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 837 Health Care Claim or Encounter EDI transaction.
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| X12N/TG2/WG3 |
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The Health Care Claim Payments Work Group (WG3) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 835 Health Care Claim Payment & Remittance Advice EDI transaction.
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| X12N/TG2/WG4 |
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The Health Care Enrollments Work Group (WG4) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 834 Benefit Enrollment & Maintenance EDI transaction.
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| X12N/TG2/WG5 |
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The Health Claims Status Work Group (WG5) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N)of X12. This group maintains the X12 276 Health Care Claims Status Inquiry and the X12 277 Health Care Claim Status Response EDI transactions.
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| X12N/TG2/WG9 |
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The Health Care Patient Information Work Group (WG9) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 275 Patient Information EDI transaction.
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| X12N/TG3 |
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The Business Transaction Coordination and Modeling Task Group (TG3) of the Insurance Subcommittee (N) of X12.TG3, maintains the X12N Business and Data Models and the HIPAA Data Dictionary.
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| X12N/TG3/WG1 |
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The Property & Casualty Work Group of the Business Transaction Coordination and Modeling Task Group (TG3) of the Insurance Subcommittee (N) of X12.
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| X12N/TG3/WG2 |
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The Healthcare Business & Information Modeling Work Group of the Business Transaction Coordination and Modeling Task Group (TG3) of the Insurance Subcommittee (N) of X12.
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| X12N/TG3/WG3 |
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The HIPAA Implementation Coordination Work Group of the Business Transaction Coordination and Modeling Task Group (TG3) of the Insurance Subcommittee (N) of X12. This was formerly X12N/TG2/WG19 and X12N/SPTG4.
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| X12N/TG3/WG4 |
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The Object-Oriented Modeling and XML Liaison Work Group of the Business Transaction Coordination and Modeling Task Group (TG3) of the Insurance Subcommittee (N) of X12.
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| X12N/TG4 |
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The Implementation Guide Task Group of the Insurance Subcommittee (N) of X12. This group supports the development and maintenance of X12 Implementation Guides, including the HIPAA X12 IGs.
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| X12N/TG8 |
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The Architecture Task Group of the Insurance Subcommittee (N) of X12. |
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