The Centers for Medicare and Medicaid Services has issued additional guidance on provider use of more standardized electronic funds transfer and electronic remittance advice transactions, and the mandate on health insurers to offer the transactions.
The EFT/ERA mandate is part of the emerging set of HIPAA operating rules to make electronic administrative and financial transactions more uniform among stakeholders. The new transactions started in 2013 with payers required to comply with operating rules for eligibility determination and claim status.
In January 2016, a batch of other operating rules go into effect covering claims/encounters, coordination of benefits, health plan enrollment/disenrollment, plan premium payment, referral certification and authorization, and claims attachments (if a standard for attachments can be agreed and ready at that time, which many doubt).
In a new frequently asked question about options available to providers to receive payments from health plans, CMS responds:
Providers have a number of choices for receiving healthcare payments from health plans, including Electronic Funds Transfer through the Automated Clearing House Network, checks, Fedwire, or through other payment networks. We encourage providers to implement the standard EFT through the ACH Network.
If a provider requests that a health plan conduct the electronic funds transfer and remittance advice transaction in standard format (by using the ACH network), then the health plan must comply with the HIPAA standard for this transaction. And if a provider requests that a health plan transmit payments consistent with the HIPAA standard, the health plan is not permitted to delay or reject a transaction because the transaction is a standard transaction (45 CFR 162.925).
The health plan also cannot incentivize a provider to use an alternate payment method other than the adopted standard or adversely affect the provider for using the standard transaction (i.e., charging excessive fees). Regardless of the method a provider chooses to receive health care payments from health plans, the provider should carefully analyze their agreements for any added fees.
CMS has additional guidance on EFT/ERA and other operating rules here. The American Medical Association in November 2013 also issued guidance and a toolkit on taking advantage of the EFT/ERA transactions, and a Health Data Management feature story walked through present and future HIPAA operating rules.
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