HIPAA ‘Operating Rule’ Requirements Issued for Eligibility, Claims Status
|Date Posted: July 14, 2011|
Uniform procedures for performing HIPAA’s eligibility and claims status transactions were codified by the U.S. Department of Health and Human Services (HHS) in interim final rules published July 8 (76 Fed. Reg. 40458). These rules, the first of many mandated by last year’s health reform law in this area, largely codify existing operating rules that were developed by an industry organization on a voluntary basis.
Health plans and other covered entities must comply with these rules by Jan. 1, 2013. Plans will be required to certify compliance by the end of 2013 or face substantial penalties.
The Patient Protection and Affordable Care Act (PPACA) requires HHS to issue operating rules for HIPAA’s standard transactions, to make the information and transmission formats more uniform and reduce the role of plan-specific “companion guides.” The agency is to appoint standards-setting bodies to develop the rules, with the input of the National Committee on Vital and Health Statistics (NCVHS).
The eligibility and claims status transactions, the first in PPACA’s timeline, are relatively low-hanging fruit because of the voluntary operating rules already developed by the Committee for Affordable Quality Healthcare’s Committee on Operating Rules for Information Exchange (CORE). HHS’ interim final regulations adopt six of CORE’s eight Phase I rules and all five of its Phase II rules.
“CORE has also demonstrated that the use of these rules yields a return on investment for both business operations and systems within today’s complex health care environment,” HHS stated in the preamble to the interim final rules.
NCVHS had recommended designating CORE as the author for the operating rules on eligibility and claims status, except retail pharmacy eligibility transactions, for which it tapped the National Council for Prescription Drug Programs (NCPDP). However, HHS decided not to adopt operating rules from NCPDP because the organization’s actual standard for these transactions “provides enough detail and clarity to operationalize the standards to the point that no gaps exist that operating rules would need to fill.”
The CORE operating rules adopted “include both infrastructure rules and data content rules,” the preamble continued. Phase I of CORE’s operating rules for the eligibility transaction “help electronically confirm patient benefit coverage, copay, coinsurance, and base deductible,” HHS stated. Phase II adds rules on sending back patient remaining deductible amounts, patient matching and claim status infrastructure, as well as more prescriptive connectivity requirements.
Next up on the PPACA timetable will be operating rules for electronic funds transfer (EFT) and remittance advice, as well as the EFT standard itself and a uniform identifier for health plans.
CORE’s operating rules, updated for the Version 5010 standards, are available on the organization’s website at http://www.caqh.org/COREv5010.php.