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      Referral Certification and Authorization

      
      Guidance for the referral certification and authorization transaction.
              Final
      
          
      **Issued by:**  Centers for Medicare & Medicaid Services (CMS)

              **Issue Date:** August 02, 2020
      
      
                                      Under HIPAA, HHS adopted standards for electronic transactions, including for referral certification and authorization.The referral certification and authorization transaction is any of the following:A request from a health care provider to a health plan to obtain an authorization of health careA request from a health care provider to a health plan to obtain authorization for referring an individual to another health care providerA response from a health plan to a health care provider about authorization and referral requests**HIPAA Adopted Standards**In January 2009, HHS adopted Version 5010 of the **ASC X12N 278** for referral certification and authorization. For more information, see the officialASC X12N website.For pharmacy-related referral certifications and authorizations, HHS adopted National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard Version D.0.****These standards apply to allHIPAA covered entities, health plans, health care clearinghouses, and certain health care providers, not just those who work with Medicare or Medicaid.

              HHS is committed to making its websites and documents accessible to the widest possible audience,
          including individuals with disabilities. We are in the process of retroactively making some documents accessible.
          If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.

      
      **DISCLAIMER:** The contents of this database lack the force and effect of law, except as
          authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically
          incorporated into a contract.  The Department may not cite, use, or rely on any guidance that is not posted
          on the guidance repository, except to establish historical facts.      
              **Topic**
  Health CareUnique ID:HHS-0938-2020-F-8306

Date Published: 12/31/2020


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