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HHS Posts Health Eligibility, Claims EDI Regs

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The U.S. Department of Health and Human Services (HHS) is setting operating rules for sending messages about health insurance eligibility and health care claim status through electronic data interchange systems (EDI).

HHS is creating the operating rules in an effort to implement a provision of the Patient Protection and Affordable Care Act of 2010 (2010) that calls for the department to bring order PPACA Compassto the use of EDI requirements that were included in the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The HIPAA EDI requirements have created a common format for exchanging health care and health insurance data, and the requirements are supposed to reduce use of paper forms and complicated strategies for coping with data format conflicts.

But “gaps created by the flexibility in the standards permit each health plan to use the transactions in very different ways,” officials say in the preamble to the interim final rule on HIPAA EDI operating rules.

There are gaps in areas such as security, user authentication and system availability, officials say.

Health plans have created more than 1,200 “companion guides” to explain how they are implementing the HIPAA requirements, according to the American Medical Association, Chicago.

The guides vary, and they are confusing doctors, hospitals and other other users.

PPACA requires HHS to try to adopt a single set of operating rules for each type of EDI transaction, to make implementation of the standards for each type of transaction as uniform as possible, officials say.

“Standards and operating rules overlap in their functions to increase uniformity, but differ in their purposes,” officials say.

Standards apply mainly to the content to be transmitted; operating rules explain how the information should be transmitted, and they also create strategies for reducing “situationality,” or the use of requirements that apply only in some situations, officials say.

The officials cite use of the name for a specific health plan as an example of situationality. Today, a user must provide the name of the health plan, as opposed to the health insurer, only if a patient is enrolled in a plan with a specific name.

PPACA requires that the new HIPAA EDI rules be consensus-based, officials say.

The National Committee on Vital and Health Statistics (NCVHS) has been in charge of helping HHS develop the new operating rules. The NCVHS has been working on operating rules for the “eligibility for a health plan” and “health care claim status” transactions since July 2010.

Two organizations – the Committee on Operating Rules for Information Exchange (CORE) at the Council for Affordable Quality Healthcare, Washington, and the National Council for Prescription Drug Programs (NCPDP), Scottsdale, Ariz. – submitted operating rule proposals.

HHS has decided to adopt the CORE “Phase I and Phase II Operating Rules for the Non-Retail Pharmacy Eligibility for a Health Plan and Health Care Claim Status Transactions,” and the NCPDP Telecommunication Standard Implementation Guide Version D.0 Operating Rules for Retail Pharmacy Transactions for retail pharmacies.

“The pharmacy industry has long been utilizing NCPDP standards to conduct electronic transactions,” officials say. “These standards provide for real-time claims adjudication, eligibility and benefit verification, real-time ordering by the physician, and sharing of medication history. We believe that the NCPDP Version D.0 standard itself provides enough detail and clarity to operationalize the standards to the point where no gaps exist that operating rules would need to fill, so that no further infrastructure or data content rules need to be adopted at this time.”

Implementing the requirements that do involve changes could cost affected entities about $136 million over 2 years, but the efficiencies gained from standardization likely would save money in the long run, officials say.

Comments on the rule are due 60 days after the rule appears in the Federal Register.

The compliance deadline for the interim final rule is Jan. 1, 2013.

HHS says it will develop a process for updating the operating rules later.


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