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 to 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.