Today, health care providers and plans use many different electronic formats for electronic transactions. Under HIPAA, the standards for electronic transactions final rule adopts eight electronic transactions and code set standards. Medi-Cal will need to accept these standards for professional, institutional, and dental claims. The new electronic transaction standards required by HIPAA impact Electronic Data Interchange (EDI) only, and are accredited by the American National Standards Institute (ANSI).

The new electronic claim format requirements will impact the data that you must submit in order for your claim to be processed. It may, therefore, require your systems to be redesigned to capture the required data. For example, pharmacy claims currently utilize a National Council for Prescription Drug Program (NCPDP) standard. However, HIPAA will require that Medi-Cal upgrade from the current NCPDP version 3.2 to the NCPDP version 5.1. Standards for the first report of injury and claims attachments will be adopted at a later date. Below is a list of the eight transactions and their corresponding numbers.