March 20, 2014
Since 2003, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) has required covered entities, such as health plans, which engage electronically in certain “standard transactions” (see below) to comply with certain technical rules. The Health Care Reform Act requires that health plans certify their compliance with these HIPAA standard transaction rules.
The Department of Health and Human Services (HHS) recently issued proposed regulations that would implement this new requirement.
Initial Compliance Certification. Although operational compliance is already required, large health plans will be required to certify their compliance with the rules for the following HIPAA standard transactions by December 31, 2015 (the “initial certification”):
- Eligibility for a health plan;
- Health care claim status; and
- Electronic funds transfers and remittance advice transactions.
There is also a December 31, 2015 deadline under Health Care Reform for a “second certification” with regard to other standard transactions, but that deadline will likely be delayed while HHS prepares regulations.
Contents of Certification. For the initial certification, health plans will be required to submit to HHS:
1. Documentation of compliance with these rules, which the third party administrators (TPAs) receive from the non-profit Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE); and
2. The number of the health plan’s covered lives.
Unique Health Plan Identifiers. The Health Care Reform Act also requires certain self-funded group health plans to obtain a 10-digit identifier called a unique health plan identifier (HPID). Please see the May 10, 2012 issue of theHRBenefitsAuthority for a brief discussion of the proposed rules on HPIDs. Large health plans are generally required to obtain an HPID by November 5, 2014. The HPID will be needed to file the certification with HHS. Applications for HPIDs are available here.
Next Steps. Although most self-funded plans have their TPAs handle claims and payment transactions, plan sponsors are ultimately responsible for compliance with these rules. Accordingly, we recommend that plan sponsors obtain an HPID before the November deadline. We also recommend that plan sponsors contact their TPAs to confirm that the TPA has documentation of its compliance with the revised standard transaction rules from the CAQH CORE.
Contact Information. For more information from Mazursky Constantine, please contact Amy Heppner (404.888.8825), Kelly Meyers (404.888.8838) For more information from VCG Consultants, please contact Leslie Schneider (770.863.3617).