When the financial transaction rules were written into HIPAA legislation in 2000, the idea was to provide uniform guidance to streamline financial and administrative transactions across the health care spectrum. Unfortunately, the rules were open to broad interpretation, with the result that tasks such as eligibility requests and claim status inquiries were handled according to the discretion of carriers and clearinghouses.
HIPAA and the Affordable Care Act
When the Affordable Care Act was signed into law in 2010, it contained mandates designed to once and for all create uniform rules for handling financial and administrative transactions in compliance with HIPAA. Section 1104 of the ACA established a national health care operating rule that would apply to these operations for all health care stakeholders. The first of these rules were published in December 2011 and applied to just two financial transactions: Eligibility for a health plan transactions and health insurance claim status inquiries. Ultimately, electronic funds transfers and remittance advice transactions were also rolled into the 2011 and 2012 regulations; trading partners had until January 2013 to comply with the national guidelines.
Now, however, the Phase IV CAQH CORE Operating Rules are poised for beta testing in the second quarter of 2016 and they apply to four new categories of financial and administrative transactions: Encounters and claims, enrollment and disenrollment in a health plan, employee premium payments, and prior authorization operations. The CAQH Committee on Operating Rules brought together key industry stakeholders and acted as the advisory body to the Department of Health and Human Services during the initial HIPAA rulemaking under the Affordable Care Act and is taking a lead role in the testing and implementation of the Phase IV guidelines.
Currently, the CAQH has enrolled vendors and health plans in its beta testing program, but volunteers may still be considered for the beta cycle. Testing is expected to continue throughout the summer, with final approval some time following the testing process.
What Is Covered by an Operating Rule?
Operating rules support the regulatory framework and mandates contained in the Affordable Care Act; they are intended to iron out any variances in standards between trading partners. In general, an operating rule covers the following key transaction components:
- rights and responsibilities of all parties in a transaction
- exception processing
- transmission formats and standards
- standards for response time
- liabilities and error resolution
Data exchange enhancements are also under consideration, including a standard Internet-based connection between trading partners to facilitate the exchange of proprietary data. Other regulations may also be promulgated which apply to uptime and downtime on insurance websites, including tracking and remediation for extended periods of downtime. There will also be a requirement for acknowledgement of receipt of transactions and expected response times for batch and real-time transactions.
On the Horizon
The CAQH CORE committee is anticipating guidance on a common format for all CORE documentation between payers and vendors so that providers will be able to track certain information sets more easily. Coordination of benefits and claims attachments are two of the documentation types that are poised for standardization under committee recommendations; however, there is still a lack of concensus throughout health care stakeholders on what format these documents should take.
Managing the documentation and standardization requirements mandated under HIPAA and the Affordable Care Act can be a challenge for many health care practices, and those practices not in compliance face the potential of crippling financial penalties and sanctions. The documentation and billing professionals at M-Scribe are knowledgeable about the ACA transaction mandates and can help you navigate the upcoming changes. Contact us today for a consultation.