Companion Guides

CareFirst has six companion guides, to be used in conjunction with the HIPAA Implementation Guides, explaining the procedures necessary for our trading partners to conduct Electronic Data Interchange (EDI) transactions. These guides will be expanded and updated as additional standard transactions are ready for testing.

Transaction standards and code sets are used to support the electronic exchange of administrative and financial health care transactions. HIPAA designates "standard" transaction formats that must be used for the following common transactions:

• Health Care Claims (837)
• Health Care Payment/Advice (835)
• Premium Payment/Order Remittance Advice (820)
• Benefit and Enrollment Maintenance (834)
• Authorizations and Referrals (278)
• Inquiry/Response for Eligibility (270/271)
• Inquiry/Response for Claim Status (276/277)
• Health Care Claim/Pharmacy NCPDP 5.1

HIPAA has also defined the code sets that will be used to classify member information. The following code sets must be used:

• Diagnoses and inpatient hospital services: International Classification of Diseases, ninth edition, Clinical Modification (ICD-10-CM)
• Institutional Services: ICD-10-CM, Volume 3 and HCFA Common Procedural Coding System (HCPCS)
• Physician Services: Current Procedural Terminology (CPT)
• Dental Services: Current Dental Terminology (CDT)
• Drugs: National Drug Code (NDC)

Inquiries regarding set-up, testing and file submissions should be directed to edidirectsubmission@carefirst.com.