HCFA adopts formats for electronic transactions
Implementation in two years
The new standard formats for data content and the formats for submitting electronic claims and other administrative health transactions have been released by the Health Care Financing Administration (HCFA).
This new national standard will replace the 400 formats for electronic health care claims now in use. Once the mandated congressional review period ends in October, the health care industry has 24 months to implement the regulation — 36 months for small health plans.
Under the new regulation, all electronic claims transactions must follow the single standardized format. Providers will still be allowed to use paper forms, but the simplified process is expected to encourage more electronic filing.
Under the new standard:
• Health plans will be able to pay providers, authorize services, certify referrals, and coordinate benefits using a standard electronic format for each transaction. Providers will also be able to
use a standard format to determine eligibility
for insurance coverage, ask the status of a claim, request authorizations for services or specialist referrals, and receive electronic remittance to post receivables.
• New standards for other common transactions and coding standards for reporting diagnoses and procedures in the transactions.
• Standard electronic formats to enroll or disenroll employees from plans and submit premium payments.
More rules expected soon
Other still-to-come related rules to look for from the Department of Health and Human Services (HHS) are: identifiers for providers and employers, standards for health data security, and standards protecting the privacy of patient health information. HHS also expects to release proposed regulations governing claims attachments (information requested by insurance plans from health care providers to justify submitted charges), the national health plan identifier, and First Report of Injury by the end of the year.
According to an analysis by the Washington, DC, office of the Medical Group Management Association, other key provisions of the regulation include:
• Uniform standards for the following: administrative and financial transactions, health claims or equivalent encounter information, health claims attachments, eligibility for a health plan, enrollment and disenrollment in a health plan, health plan premium payments, health care payment and remittance advice, health claim status, and referral certification and authorization.
• Transmission of nonstandard transactions between a provider and a health plan or a provider and a health care clearinghouse do not violate the law if part of a trading partner agreement.
• Local codes are eliminated, and a national process is established for reviewing and approving codes.
• Current Procedural Terminology codes will be used for procedure reporting.
• International Classification of Diseases,
9th Edition, Clinical Modification codes for diagnoses. Current Dental Terminology codes are to be used for dental services. American National Standards Institute Accredited Standards Committee X12N codes are to be used for most business applications.
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