Rule Development
Rulemaking to Support Standards and Operating Rule Requirements. Instructs HHS to issue rules to implement new and amended standards and operating rules for electronic administrative and financial transactions.
- Adopts Operating Rules – to create as much uniformity as possible in implementing electronic standards – for each individual standard transaction. (PPACA § 1104)
- Establishes a unique health plan identifier, effective 10/1/12. (PPACA § 1104)
- Establishes a standard and associated operating rules for health claims attachments, effective 1/1/16. (PPACA § 1104)
- Establishes a standard for electronic funds transfers, effective 1/1/14. (PPACA § 1104)
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Compliance Process
Compliance Process for Health Plans. New compliance process establishes a requirement for health plans and their associated service contractors and business associates to document to HHS their compliance with standards and operating rules.
- Health plans must certify that their data and information systems are in compliance with standards and operating rules. (PPACA § 1104)
- Compliance will be based on the effective date of applicable standards and operating rules. (PPACA § 1104)
- Health plans must be able to document end to end testing with trading partners. (PPACA § 1104)
- Health plans must ensure entities that provide services under contract with the plan are in compliance. (PPACA § 1104)
- Requires periodic audits to ensure health plan compliance. (PPACA § 1104)
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Standardization
Transaction Standardization. Specifies the new or revised standards that must be used for the electronic exchange of administrative and financial transactions.
- References all existing HIPAA transactions. (PPACA § 1104)
- Adds standard for claims attachments. (PPACA § 1104)
- Adds standard for electronic funds transfers. (PPACA § 1104)
- Refers to ICD 9 to ICD 10 crosswalk posted on CMS website as a standard. (PPACA § 10109)
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Penalties
Penalties for Health Plans. Establishes new health plan penalties against plans that fail to provide sufficient documentation showing they are certified to be in compliance.
- Establishes penalties for failure to meet requirements. (PPACA § 1104)
- Penalty amount is $1 per covered life for each day not in compliance. (PPACA § 1104)
- Additional penalties apply for misrepresentation. (PPACA § 1104)
- Maximum penalties $20 per covered life or $40 per covered life if misrepresentation determined. (PPACA § 1104)
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Adoption Requirements
Timeframe for Adoption. Specifies the timeframes for the adoption of the new health plan identifier and for both new and revised standards and operating rules.
- Adopts operating rules for eligibility and claim status transactions by 7/1/11. (PPACA § 1104)
- Adopts operating rules for electronic payment and remittance advice by 7/1/12. (PPACA § 1104)
- Adopts operating rules for claims, enrollment, premium payments and referral transactions by 7/1/14. (PPACA § 1104)
- Adopts a standard for electronic funds transfers by 1/1/14. (PPACA § 1104)
- Adopts standard and associated operating rules for claims attachments by 1/1/14. (PPACA § 1104)
- Establishes a unique health plan identifier by 10/1/12. (PPACA § 1104)
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Additional Requirements
Additional Requirements. Instructs HHS to establish requirements for both HHS and various entities involved in processes related to the creation and maintenance of standards and operating rules.
- Specifies the qualification requirements for entities that develop operating rules. (PPACA § 1104)
- Identifies actions to be taken by the National Committee on Vital and Health Statistics (NCVHS) related to operating rules development. (PPACA § 1104)
- Establishes an operating rules review committee by 4/1/14. Could include NCVHS. (PPACA § 1104)
- Instructs HHS to solicit industry input on the need for greater uniformity in financial and administrative transactions every 3 years, starting 1/1/12. (PPACA § 10109)
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