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CCH® BENEFITS — 07/11/11

HHS Releases Operating Rules For Health Care Claims Transactions

from Spencer’s Benefits Reports: The Department of Health and Human Services (HHS) has issued an interim final rule implementing Sec. 1104(b)(2) of the Patient Protection and Affordable Care Act (ACA) to adopt a single set of operating rules “with the goal of creating as much uniformity in the implementation of the electronic standards as possible.” Sec. 1104(a)(2) establishes new requirements for administrative transactions that are intended to improve the utility of the existing transactions under the Health Insurance Portability and Accountability Act (HIPAA) and reduce administrative costs.

The rule, scheduled to be published in the July 8 Federal Register, has a compliance date of Jan. 1, 2013.

Congress addressed the need for a consistent framework for electronic health care transactions and other administrative simplification issues through HIPAA, which required the adoption of standards for certain transactions to enable health information to be exchanged electronically and to achieve greater uniformity in the transmission of health information. In 2010, the ACA mandated a single set of operating rules.

The July 2011 new single set of operating rules mandated by the ACA augment the standards in the following three ways:

• They contain additional requirements that help implement the standard for a transaction in a more consistent manner across health plans. For example, when a provider currently sends an eligibility for a health plan inquiry to a health plan, the standard allows responses ranging from a simple “yes” or “no,” to the inclusion of a complete range of information. The operating rule requires the health plan to return patient eligibility and financial responsibility for a specified list of service type codes including, but not limited to, dental, vision, medical, hospital inpatient, and emergency care. This requirement ensures that a provider receives a consistent response for an eligibility for a health plan inquiry.
• They address ambiguous or conditional requirements in the standard and clarify when to use or not use certain data elements or code values. For example, the standard may leave it to the discretion of the health plan whether or not to return the health plan’s name in a particular field, creating the possibility of inconsistency in health plan responses. An operating rule may require that the health plan name always be returned and that it always be returned in one particular specified manner. This encourages uniformity and alleviates the problem of providers receiving inconsistent information.
• They specify how trading partners, including providers, should communicate with each other and exchange patient information, with the goal of eliminating connectivity inconsistencies. Currently, individual health plans specify the transmission methods they expect each of their trading partners, including providers, to use for electronic transactions. Mandating one uniform method decreases the amount of work and inconsistencies providers experience when dealing with multiple payers with differing transmission methods.

Comments are due 60 days after publication the Federal Register and should be sent via the Federal eRulemaking Portal at http://www.regulations.gov; or by mail to Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-0032-IFC, P.O. Box 8013, Baltimore, MD 21244-8013. Refer to file code CMS-0032-IFC.

For more information, contact one of the following at HHS:

Shannon Whetzel at (410) 786-3267; Matthew Albright at (410) 786-2546; or Denise Buenning at (410) 786-6711.

For more information on this and related topics, consult the CCH Pension Plan Guide, CCH Employee Benefits Management, and Spencer's Benefits Reports.

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