HIPAA Regulatory Alert

Standards in place for electronic transmission

The Centers for Medicare and Medicaid Services (CMS) has issued an interim final rule to adopt the first two in a series of "operating rules" that will standardize the HIPAA standards for electronic administrative/financial transactions.

Adoption of operating rules between 2013 and 2016 is mandated under the Affordable Care Act. Under the interim final rule, CMS adopts the Committee on Operating Rules for Information Exchange (CORE) operating rules for the insurance eligibility verification/benefit determination and claim status transactions. CORE is an initiative of the Council for Quality Healthcare, an alliance of health plans and healthcare industry representatives.

Under the CORE rules, the payer will provide additional information, including benefit levels, co-pays, and deductibles, to enable the provider to know the patient's payment responsibility at the point of service.

Under the Affordable Care Act, CMS must adopt rules for eligibility and claims status transactions effective Jan. 1, 2013. Rules for electronic funds transfer and payment/remittance advice transactions must be adopted by July 1, 2012, effective Jan. 1, 2014. CMS must adopt rules for claims/encounters, enrollment/disenrollment, health plan premium payments, and referral certification /authorization by July 1, 2014, effective Jan. 1, 2016.

CMS will accept public comment on the interim final rule through the business day on Sept. 6. To see the interim final rule, go to http://www.ofr.gov/OFRUpload/OFRData/2011-16834_PI.pdf.