Administrative Simplification:
The Next Round of HIPAA
HIPAA COW Spring Conference 2012
Gail Kocher
Admin Simp: The Next Round of HIPAA
Overview
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Administrative Simplification Timelines
Operating Rules
– Eligibility
– Claim Status
New Standards
– Electronic Funds Transfer (EFT) and Remittance Advice
Impacts, Challenges and Next Steps
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Admin Simp: The Next Round of HIPAA
Administrative Simplification Timelines
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Regulation Compliance Date:
– January 1, 2013 – Operating Rules for Eligibility and Claim Status
– January 1, 2014 – Electronic Funds Transfer (EFT) Standard
Statute Effective Date no later than:
– October 1, 2012 –Health Plan ID Standard
– December 31, 2013 – Health Plans to certify compliance with Standards
and Operating Rules for Eligibility/Claim Status, Electronic Remittance
Advice (ERA) and Electronic Funds Transfer (EFT)
– January 1, 2014 – Operating Rules for ERA and EFT
– December 31, 2015 – Health plans to certify compliance with Standards and
Operating Rules for Claims, Enrollment, Premium Payment and
Referral/Preauthorizations
– January 1, 2016 – Claims Attachments Standard and Operating Rules
– January 1, 2016 – Operating Rules for Claims, Enrollment, Premium
Payment and Referral/Preauthorizations
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Admin Simp: The Next Round of HIPAA
Operating Rules
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Interim Final Rule (IFC)
– Published July 8, 2011
– Effective June 30, 2011
– Compliance Date January 1, 2013
– Notice issued December 7, 2011 confirming IFC as published July 8, 2011 is
final rule in effect
New definitions
– Operating rules means the necessary business rules and guidelines for the
electronic exchange of information that are not defined by a standard or its
implementation specifications as adopted for purposes of this part.
– Standard transaction means a transaction that complies with an applicable
standard and associated operating rules adopted under this part.
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Admin Simp: The Next Round of HIPAA
Operating Rules: Eligibility
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CORE Phase I Policies and Operating Rules Version 1.1.0, March 2011
– Phase I CORE 152: Eligibility and Benefit Real Time Companion Guide
Rule
– Phase I CORE 153: Eligibility and Benefits Connectivity Rule
– Phase I CORE 154: Eligibility and Benefits 270/271 Data Content Rule,
– Phase I CORE 155: Eligibility and Benefits Batch Response Time Rule
– Phase I CORE 156: Eligibility and Benefits Real Time Response Time Rule
– Phase I CORE 157: Eligibility and Benefits System Availability Rule
CORE Phase I Policies and Operating Rules Version 1.2, March 2011
– ACME Health Plan, HIPAA Transaction Standard Companion Guide, Refers
to the Implementation Guides Based on ASC X12 version 005010, CORE
v5010 Master Companion Guide Template, 005010
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Admin Simp: The Next Round of HIPAA
Operating Rules: Eligibility
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Version 2.1.0, March 2011
– Phase II CORE 258: Eligibility and Benefits 270/271 Normalizing Patient
Last Name Rule
– Phase II CORE 259: Eligibility and Benefits 270/271 AAA Error Code
Reporting Rule
– Phase II CORE 260: Eligibility & Benefits Data Content (270/271) Rule
– Phase II CORE 270: Connectivity Rule
Excludes
– Where the CAQH CORE rules reference and pertain to acknowledgements
and CORE certification
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Admin Simp: The Next Round of HIPAA
Operating Rules: Claim Status
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CORE Phase I Policies and Operating Rules Version 1.2, March 2011
– ACME Health Plan, HIPAA Transaction Standard Companion Guide, Refers
to the Implementation Guides Based on ASC X12 version 005010, CORE
v5010 Master Companion Guide Template, 005010
Version 2.1.0, March 2011
– Phase II CORE 250: Claim Status Rule
● Includes infrastructure rules based on Phase I within this Phase II rule,
e.g. system availability, response time
– Phase II CORE 270: Connectivity Rule
Excludes
– Where the CAQH CORE rules reference and pertain to acknowledgements
and CORE certification
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Admin Simp: The Next Round of HIPAA
Standards: Electronic Funds Transfer (EFTs)
& Remittance Advice
● Interim Final Rule (IFC)
– Published January 10, 2012
– Effective January 10, 2012
– Compliance Date January 1, 2014
● New Definitions
– Stage 1 payment initiation means a health plan’s order, instruction or
authorization to its financial institution to make a health care claims payment
using an electronic funds transfer (EFT) through the ACH Network.
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Admin Simp: The Next Round of HIPAA
Standards: Electronic Funds Transfer (EFTs)
& Remittance Advice
● January 1,2012 through December 31, 2013
– ASC X12 Health Care Claim Payment/Advice (835), version 005010
● On and after January 1, 2014
– NACHA Corporate Credit or Deposit Entry with Addenda Record (CCD+)
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implementation, version 2011 NACHA Operating Rules & Guidelines
For the CCD Addenda Record (‘‘7’’), field 3, of the NACHA standard, ASC
X12 Health Care Claim Payment/Advice (835), version 005010 TRN
Reassociation Trace Number
ASC X12 Health Care Claim Payment/Advice (835), version 005010
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Admin Simp: The Next Round of HIPAA
Impacts, Challenges and Next Steps
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Operating Rules: Providers
– Analyze current implementations
● Generation of eligibility* and claim status requests
– Review patient data collection processes (identification card)
– Timing of requests against patient's appointment
– Timing of status request against claim submission
● Practice Management System
– *Benefits eligibility – can it process the data?
– *Co-pay, deductible, co-insurance, etc – can it capture it?
– Software updated to accommodate operating rules?
● Outbound transaction edits
– Workflow impacts to follow-up from eligibility determination or
claim status
* Eligibility only
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Admin Simp: The Next Round of HIPAA
Impacts, Challenges and Next Steps
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Operating Rules: Providers
– Batch vs. real-time workflow impacts
– Connectivity – need to determine whether connectivity with trading partners
will change
– Gather trading partner testing and implementation information
● Variation in testing and implementation timeframes across payers
impacts provider implementations
● PMS updates may impact testing and implementation timeframe on
provider side
– Follow-up with trading partners routinely – two-way communication
– New companion guides
● Requires review for new information
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Admin Simp: The Next Round of HIPAA
Impacts, Challenges and Next Steps
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Operating Rules: Payers
– Analyze current implementations
● Response to eligibility* and claim status requests
– Front-end transaction edits updated to accommodate operating
rule changes, inbound and outbound
– Systems available per new system availability timeframes
– Response time requirements
– *Patient financial liability data requirements
● Co-pay, deductible, co-insurance
– *Health Plan and Benefit-Specific base deductible dates
– *Normalizing Patient Last Name
– *AAA Error Coding
* Eligibility only
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Admin Simp: The Next Round of HIPAA
Impacts, Challenges and Next Steps
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Operating Rules: Payers
– Connectivity
● Can provisions be met or are systems changes needed to meet
requirements?
– Companion Guides
● May be a new format – need time for creation and provider education
– Issue communication on testing and implementation to all trading partners
timely
– Follow-up with trading partners routinely – two-way communication
– Short timeframes for implementation if this is initial adoption of CORE rules
– Multiple documents needed for implementation
● TR3 and errata (when applicable)
● Phase I and Phase II rule documents
– Internal training, e.g. customer service
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Admin Simp: The Next Round of HIPAA
Impacts, Challenges and Next Steps
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Operating Rules: Clearinghouses/Billing Services
– Analyze current implementations
● Pass through transaction edits updated to accommodate operating rule
changes
● Systems available per new system availability timeframes
● Response time requirements
– Connectivity
● Can provisions be met or are systems changes needed to meet
requirements?
– Companion Guides
● May be a new format – need time for creation and provider education
– Internal training, e.g. customer service, both provider and payer teams
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Admin Simp: The Next Round of HIPAA
Impacts, Challenges and Next Steps
●
Operating Rules: Clearinghouses/Billing Services
– Issue communication on testing and implementation to all trading partners
timely
– Follow-up with trading partners routinely – two-way communication
– Short timeframes for implementation if this is initial adoption of CORE rules
– Multiple documents needed for implementation
● TR3 and errata (when applicable)
● Phase I and Phase II rule documents
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Admin Simp: The Next Round of HIPAA
Impacts, Challenges and Next Steps
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Standards: Providers
– Practice Management System
● Capability to autopost remittance?
● Capability to bring in financial data from bank?
● Capable of reconciling the two from reassociation data?
– Enrollment process with payer and bank
– Identification of payer-provider relationship/contract
● e.g. NPI, Tax ID
● Variation by payer
– Training if new to EFT
– Comfort level in moving to EFT, i.e. accounts receivable is managed
● Timing between receipt of EFT and remittance
– Operating rules not yet adopted, additional impacts may result
– Communication with trading partners on testing, implementation, etc is key
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Admin Simp: The Next Round of HIPAA
Impacts, Challenges and Next Steps
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Standards: Payers
– Analyze current implementations
● Insure EFT includes reassociation data
– Evaluation of enrollment and authorization requirements for providers
● New data collection may be needed to support EFT
– Identification of payer-provider relationship/contract
● e.g. NPI, Tax ID
– Internal training, e.g. customer service, both provider and payer teams
– Timing when passing EFT and remittance transactions
– Operating rules not yet adopted, additional impacts may result
– Communication with trading partners on testing, implementation, etc is key
* Eligibility only
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Admin Simp: The Next Round of HIPAA
Impacts, Challenges and Next Steps
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Standards: Clearinghouses/Billing Services
– Analyze current implementations or new implementation if not currently
exchanging EFT or remittance transactions
– Evaluation of enrollment and authorization requirements for providers
– Evaluation of enrollment requirements with payers
– Internal training, e.g. customer service
– Timing between issuing EFT and remittance
– Operating rules not yet adopted, additional impacts may result
– Communication with trading partners on testing, implementation, etc is key
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Admin Simp: The Next Round of HIPAA
Open Discussion
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Questions?
Other impacts?
Other challenges?
Other next steps?
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Admin Simp: The Next Round of HIPAA
Resources
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WEDI website
– www.wedi.org
Strategic National Implementation Process (SNIP)
– White papers, issue briefs
● http://www.wedi.org/snip/public/articles/dis_publicDisplay.cfm?docType
=6&wptype=3
– EFT NPI Utilization Issue Brief
– Subworkgroups
● http://www.wedi.org/snip/index.shtml
– 835 – scope includes EFT
– 27X – eligibility, claim status and referral/preauthorizations
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Administrative Simplification:
The Next Round of HIPAA
HIPAA COW Spring Conference 2012
Gail Kocher
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