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Inside the Health Plan Compliance Certification Proposed Rule

Margaret Dick Tocknell, for HealthLeaders Media, January 8, 2014

HHS wants to ensure that health plan IT systems meet interoperability standards to exchange information with providers. A proposed rule is now open for public comment.

Hey, health insurers: Washington feels your pain!

Many of you have complained that a lack of consistent testing processes hindered your efforts to comply with HIPAA standards and operating rules for certain types of electronic healthcare transactions, including electronic funds transfers or EFTs.

Well, the Department of Health and Human Services has taken your complaints to heart. Earlier this month it released a proposed rule [PDF] designed to serve as "an initial step" toward the development of "consistent testing processes" that will (hopefully) enable health plans to "better achieve and demonstrate" compliance with HIPAA standards.

In other words, HHS wants to make sure that health plan IT systems meet interoperability standards to exchange information with providers.

Basically, the rule defines the information and documentation (more on this later) that must be submitted to prove that a health plan has tested its IT system and meets HIPAA standards for these specific electronic transactions: insurance eligibility, healthcare claim status, and healthcare EFTs and electronic remittance advice (ERA).

Health plans would have until Dec. 31, 2015 to submit their documents of attestation. After that date procrastinators could face a penalty fee of $1 per day per covered life (not to exceed $20 per covered life) until certification is achieved. The maximum penalty doubles to $40 per covered life if a health plan knowingly provides inaccurate or incomplete information in the certification process.

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