The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicaid and all other health insurance payers in the United States, comply with the EDI standards for health care as established by the Secretary of Health Services. The ANSI X12N implementation guides have been established as the standards of compliance for claim transactions.

This page provides access to information intended to serve only as a companion guide to the HIPAA ANSI X12N implementation guides. The use of this guide is solely for the purpose of clarification. The information describes specific requirements to be used for processing data. This companion guide supplements, but does not contradict any requirements in the X12N implementation guide.

Additional information on the Final Rule for Standards for Electronic Transactions can be found at http://aspe.hhs.gov/admnsimp/final/txfin00.htm. The HIPAA Implementation Guides can be accessed at http://www.wpc-edi.com/hipaa/HIPAA_40.asp.

The information in these guides is subject to change. Please check this site periodically to obtain the most current information available from Florida Medicaid. If you have any questions regarding these Companion Guides, please contact EDI Services.

Claim Adjustment and EOB Crosswalk

The HIPAA standard claim adjustment reason codes and remark codes have been cross-walked to the Medicaid EOBs. The HIPAA standard codes do not communicate the same level of detail about the claim as the Medicaid EOBs. Review the Crosswalk of X12 Codes to EOB Codes for more details.

Additional HIPAA information is available on the Agency for Health Care website at ahca.myflorida.com.

EOB Message Codes and Descriptions

The EOB Message Codes and Descriptions (New 7/26/2011) document provides a current version of the Explanation of Benefits (EOB) codes and associated messages that are used in the new FMMIS. These codes are provided as a reference and may periodically be revised.

TPL Recovery Adjustment Reason Codes

The TPL Recovery Adjustment Reason Codes provides an explanation and contact information for Third Party Liability Recovery Codes.

5010 Companion Guides - Updated January 6, 2012

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