3/3 Deadline To Comment On HHS Proposed Health Plan Certification of EDI Compliance Rule

March 3, 2014

Today (March 3, 2014) is the deadline for controlling health plans  (“CHPs) and other concerned parties to comment on the “Administrative Simplification: Health Plan Certification of Compliance” rule (Proposed Rule) published by the Department of Health & Human Service (HHS) on January 2, 2014.  If adopted as published, CHPs would be required to prepare and file the required certification with HHS by December 15, 2015.

HHS plans to use the Proposed Rule to implement the requirement of Section 1173(h)(1)(A) of the Patient Protection and Affordable Care Act (ACA) that CHPs file a statement with HHS certifying that the health plan is in compliance with the adopted standards and operating rules for electronic transactions for Eligibility for a health plan, health care claim status, health care electronic funds transfers (EFT) and remittance advice transactions established as part of the Standards for Electronic Transactions Final Rule (ET Standards) of the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Requirements (the “First Certification”).

Beyond the First Certification, ACA Section 1173(h)(1)(B) separately mandates health plan certification of compliance by December 31, 2015 for the following HIPAA transactions: Health care claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, health claims attachments, and referral certification and authorization. Meanwhile ACA section 1173(h)(5) of the Act mandates that health plans meet certification of compliance requirements for later versions of the standards and operating rules.

The Proposed Rule only covers the First Certification. Guidance on the other certification rules will be separately published.

When adopted, the Proposed require that CHPs to submit the First Certification to HHS on or before December 31, 2015 certifying and demonstrating the CHPs compliance with these adopted standards and operating rules for three electronic transactions.

The following Table 1 displays the specific standards and operating rules to which the requirements for the First Certification of compliance apply.

To comply with the First Certification requirement, CHPs will have to conduct the necessary testing to be able to verify that the CHP has conducted testing and verified the health plan’s compliance with HIPAA’s electronic transactions standards for health plans concerning:

  • Eligibility for health plan coverage
  • Health care claim status
  • Health care electronic funds transfers (EFT) and remittance advice

The Proposed Rule proposes the requirements for certification and the penalties that will apply to a CHP that fails to comply with the certification of compliance requirements.

HHS is accepting public comments on the proposed rule through March 3, 2014.

For Representation, Training & Other Resources

If you need assistance monitoring these and other regulatory policy, enforcement, litigation or other developments, or to review or respond to these or other workforce, benefits and compensation, performance and risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer may be able to help.

Board Certified in Labor & Employment Law, Past Chair of the ABA RPTE Employee Benefit & Other Compensation Arrangements Group, Co-Chair and Past Chair of the ABA RPTE Welfare Plan Committee, Vice Chair of the ABA TIPS Employee Benefit Plans Committee, Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 25 years’ experience advising health plan and employee benefit, insurance, financial services, employer and health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers, health plans, their business associates and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. She regularly designs and presents HIPAA and other risk management, compliance and other training for health plans, employers, health care providers, professional associations and others.

Ms. Stamer also regularly works with OCR, FTC, USSS, FBI and state and local law enforcement on privacy, data security, health care, benefits and insurance and other matters, publishes and speaks extensively on medical and other privacy and data security, health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. For instance, Ms. Stamer for the third year will serve as the appointed scribe for the ABA Joint Committee on Employee Benefits Agency meeting with OCR. Her insights on HIPAA risk management and compliance frequently appear in medical privacy related publications of a broad range of health care, health plan and other industry publications Among others, she has conducted privacy training for the Association of State & Territorial Health Plans (ASTHO), the Los Angeles Health Department, the American Bar Association, the Health Care Compliance Association, a multitude of health industry, health plan, insurance and financial services, education, employer employee benefit and other clients, trade and professional associations and others.  You can get more information about her HIPAA and other experience here.

You can review other recent human resources, employee benefits and internal controls publications and resources and additional information about the employment, employee benefits and other experience of the Cynthia Marcotte Stamer, PC here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile www.cynthiastamer.com or by registering to participate in the distribution of these and other updates on our HR & Employee Benefits Update distributions here including:

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