ADMINISTRATIVE SIMPLIFICATION

Administrative Simplification

The U.S. Department of Health and Human Services (HHS) published a proposed rule requiring all health plans to submit information and documentation demonstrating compliance with standards and operating rules for certain electronic transactions.

Key organizations:

  • CAQH: Council for Affordable Quality Health Care
  • CORE: CAQH’s Committee on Operating Rules on Information Exchange

Proposed rule requirements:

  • Controlling health plans*, including self-funded plans, have to get either a CAQH/CORE “seal” or a “HIPAA” credential showing that they meet HIPAA electronic standard transactions; and
  • Controlling health plans, including self-funded plans, have to send proof that they received this certification.

Proposed certification deadlines
According to the proposed rule, a controlling health plan that obtains an HPID**:

  • before Jan. 1, 2015, must meet the submission requirements for the first certification of compliance on or before Dec. 31, 2015.
  • on or after Jan. 1, 2015, and on or before Dec. 31, 2016, must meet the submission requirements for the first certification of compliance within 365 calendar days of obtaining an HPID.
  • after Dec. 31, 2016, is not required to meet the requirements proposed in this rule for the first certification of compliance.

*Controlling health plans control their own business activities, actions or policies, or are controlled by an entity that is not a health plan.
**On Oct. 31, 2014, HHS announced a delay in enforcing HPID requirements until further notice.

Administrative Simplification and Certification of Compliance for Health Plans Proposed Rule