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Current Initiatives

Health and Human Services (HHS)/ Centers for Medicare and Medicaid Services(CMS) HIPAA Transactions Compliance Review Program (CRP)


Late March 2019, CMS on behalf of HHS, announced their plans to launch a CRP to ensure HIPAA covered entities comply with HIPAA named and adopted electronic healthcare administrative transaction standards. Starting in April 2019, HHS will randomly select a mix of 9 HIPAA covered entity health plans and clearinghouses every year –– for compliance reviews. When selected for compliance review, TRICARE as a Health Plan will have 30 days to complete a HIPAA transactions compliance review and provide results to CMS.


DHA's HIPAA TCS&I office received CMS' initial announcement about the CRP and communicated with key DHA stakeholders toward rapidly executing a CRP when the time comes. For more information, please email the HIPAA TCS&I Office.

Proposed Modification to Currently Adopted NCPDP D.0 Standard for Pharmacy Claims

On January 31, 2019, the Department of Health and Human Services (HHS) released a Notice of Proposed Rule Making (NPRM) that would require modification to the currently-adopted National Council on Prescription Drug Programs (NCPDP) Telecommunication Standard Version D.0 pharmacy claim transaction. The proposed rule would require covered entities to include the “Quantity Prescribed” field for retail pharmacy transactions for Schedule II drugs (e.g., opioids). The NPRM can be found here.

The intent of the rule is to better track opioid prescriptions to manage patients' consumption and reduce the number of "excess" pills that may end up being illicitly resold.

The MHS HIPAA Transactions Code Sets, and Identifiers Office coordinated review of the proposed rule with MHS pharmacy claim stakeholders to assess the impact and any potential concerns. The public comment period for the NPRM closed on April 1, 2019; further action will continue once a final rule is published.

MHS Efforts to Review Draft X12 Version 7030 Implementation Guides

X12 Incorporated (pronounced ex-12) is named in the Health Insurance Portability and Accountability Act (HIPAA) as a standards organization responsible for developing and maintaining electronic transaction standards for HIPAA-adopted healthcare administrative simplification (e.g., for eligibility, enrollment, referrals, claims, and claim payments). X12 is in the process of developing new versions of HIPAA transaction standards to replace the current HIPAA-adopted and implemented Version 5010. The new version is called Version 7030.

X12 is in the process of releasing draft versions of respective Version 7030 HIPAA transaction standards for review and comment by X12 members. Each respective Version 7030 standard has or is expected to have a designated period for the members to review and provide input. The Defense Health Agency (DHA) HIPAA Transactions, Code Sets & Identifiers (TCS&I) Office is the sole X12 voting member for the Military Health System (MHS); as such, the HIPAA TCS&I Office is facilitating the MHS review and feedback to X12 during each designated Version 7030 draft transaction standard review period. In order to facilitate X12’s consideration of MHS business process needs, the HIPAA TCS&I Office solicits input and coordinates with applicable MHS functional and technical stakeholders to support their specific needs related to the respective HIPAA transaction.

Process Phases

The HIPAA TCS&I Office-facilitated guide review process includes five phases.

  • Discovery Phase:  Includes obtaining and pre-accessing the draft Version 7030 transaction guide and associated 7030 vs. 5010 change log.
  • Preparation Phase:  Includes combining the change log and other guide assessment findings into a structured change analysis tool for review by the HIPAA TCS&I Office and applicable MHS stakeholders.
  • Review Phase:  Includes analyzing the transaction changes, providing the structured change analysis tool to stakeholders, and facilitating live guide review sessions. Includes MHS stakeholder reviews.
  • Approve Phase:  Includes collecting, aggregating, and reviewing stakeholder feedback and escalating, as needed, through DHA leadership.
  • Finalize Phase:  Includes submitting consolidated MHS comments to X12 and coordinating with applicable MHS stakeholders, as needed, on any resulting responses from X12.

Timing and Duration of X12 Draft Version 7030 Transaction Implementation Guide Reviews 

View Draft Version 7030 Dashboard Metrics for change analysis updates.

Transactions for Future Review:

(Note:  The dates and durations of the respective review periods are to be determined)

  • Health Care Claim Request for Additional Information (277RFI)
  • Additional Information to Support a Health Care Claim or Encounter (275)
  • Additional Information to Support a Health Care Services Review (275)

Transactions Reviewed To Date:

  • Health Care Eligibility/Benefit Inquiry and Response (270/271):  16 July 2018 - 16 November 2018
  • Health Care Services Request for Review and Response (Prior-Authorizations/Referrals (278)):     1 September 2017 - 30 November 2017
  • Health Care Claim - Dental (837D):  1 February 2017 - 1 June 2017
  • Health Care Claim - Institutional (837I):  1 February 2017 - 1 June 2017
  • Health Care Claim - Professional (837P):  1 February 2017 - 1 June 2017
  • Health Care Claim Payment/Remittance Advice (835):  1 November 2016 - 30 January 2017
  • Health Care Claim Status Request and Response (276/277):  1 October 2016 - 30 November 2016
  • Benefit Enrollment and Maintenance (834):  1 September 2016 - 31 October 2016

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