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Inside the Health Plan Compliance Certification Proposed Rule

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

The proposed rule runs about 100 pages. Here are salient points:

1. Why is this rule necessary?
This dates back to the Health Insurance Portability and Accountability Act, which became law in 1996. With an eye to reducing administrative costs, the law encourages the use of electronic transactions and entrusts HHS with setting the standards and operating rules to reduce the healthcare industry's reliance on paper and manual processes.

Compliance dates were set, but health plans had a difficult time meeting the deadlines. Typically, HHS responded by delaying implementation or relaxing enforcement, but the industry has been unhappy with that approach because, as stated in the proposed rule, "such practices can be expensive to the industry."

2. Who must comply?
A health plan, any health plan subsidiary, and any business that conducts those applicable electronic transactions on behalf of a health plan must comply with the proposed rule.

3. What documentation must be submitted?
There are two types of evidence of compliance, both issued by the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE):

  • CAQH CORE certification (also known as the Phase III CORE Seal).
    This requires testing by a CORE-authorized vendor and compliance with CORE standards, as well as a gap analysis to determine what system and business process changes may be necessary for a health plan to make.
  • HIPAA Credential from CORE documenting compliance with HIPAA standards.
    CAQH CORE is still developing this credential, but when finalized it is expected to require attestation to compliance with HIPAA standards and operating rules for eligibility. The health plan will attest that it successfully tested at least 30% of its total transactions with at least three providers for three electronic transactions. Contact information for the providers must also be submitted.
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