New HHS FAQs as of 11/02/2001

[Zon Owen]

Aloha!   HHS has just posted a new group of submitted questions and answers on the main Administrative Simplification web site.  I am including them as reformatted below for your convenience.  Plan A is to incorporate both these 11/02/2001 items and the 09/17/2001 items in an updated FAQ analysis (Version 4.0) within the next week.   << Begin HHS 11/02/2001 FAQ Quotes >>   11/2/2001 Question 1:  Does the Transactions Rule affect health plan transmission requirements? May a health plan continue to require health care providers to send dental claim transactions to one location (electronic mail box, etc.) and preauthorization transactions to another?   11/2/2001 Answer 1:  The Transactions Rule does not affect transmission requirements, such as specified billing addresses, of health plans. These are business decisions between health plans and health care providers. HIPAA does require health plans to accept the electronic transactions which were adopted through the transaction rule.   11/2/2001 Question 2:  Is a health plan required to use the standard transaction when performing coordination of benefits (COB) with an automobile insurance company?   11/2/2001 Answer 2:  Property and casualty insurance programs are not included within the definition of health plan, so they are not required to use the standard transactions. However, they may do so if they wish, and if they use the standard COB transaction in performing coordination of benefits with a health plan with which they have trading partner agreements to conduct COB, the health plan is required to accept the standard transaction.   11/2/2001 Question 3:  Our business provides administrative services to large group physician practices. As part of this service, we collect demographic and clinical information from hospitals and other venues where the group physicians perform services. We send this information electronically to the physicians' billing offices to use in preparing bills to send to various health plans. Do these transmissions have to be in HIPAA standard format?   11/2/2001 Answer 3:  The activity you describe does not meet the definition of a health claim transaction or any other transaction for which standards have been adopted under 45 CFR Part 162, subparts K through R. These transmissions therefore do not have to be conducted as standard transactions. The bills sent by the physicians' billing offices to the health plans must be in standard format.   11/2/2001 Question 4: If a health care provider electronically conducts a non-compliant transaction (transmits an old National Standard Format or a proprietary format) directly to a health plan after the transaction regulation compliance date, and the health plan accepts and processes the non-compliant transaction, who is in violation of the regulation? Is it the health care provider or the health plan? Does the acceptance and processing of a non-compliant transaction by a health plan from a health care provider constitute a violative trading partner agreement between the health plan and the health care provider?   11/2/2001 Answer 4:  If a health care provider electronically conducts a non-standard transaction with a health plan after the transaction regulation compliance date, the health care provider and the health plan are both out of compliance. Section 162.923(a) of the rule requires a covered entity conducting an electronic transaction for which a standard has been adopted with another covered entity to conduct it as a standard transaction.   If the health plan by agreement required the health care provider to conduct non-standard electronic transactions, such agreement would not by its terms violate section 162.915. However, if either party were to abide by the agreement, they would be out of compliance with section 162.923(a), for the reason stated above.   11/2/2001 Question 5:  As a health plan we currently only conduct coordination of benefits (COB) with Medicare. Does the transaction and code set regulation require health plans to conduct COB with all health plans and health care providers even though they may not currently conduct COB with those entities?   11/2/2001 Answer 5:  No. It is the health plan's decision as to whether they coordinate benefits electronically with another health plan or a health care provider. If a health plan decides to coordinate benefits electronically with another health plan or a health care provider, they must use the standard transaction for COB. << End HHS 11/02/2001FAQ Quotes >>   The most interesting of these from my perspective is item number 4.  This answer clarifies that the submission and acceptance of a non-compliant electronic transaction format is a violation for both the sending and receiving parties, and not just the submitting party.  I have previously noted that the transaction rule becomes self-enforcing under this interpretation, since you would need legal signoffs by all associated trading partners to use an alternate format, which wouldn't generally be practical to achieve.    - Zon Owen - (808)597-8493   ********************************************************************** To be removed from this list, go to: http://snip.wedi.org/unsubscribe.cfm?list=business and enter your email address.