The National Committee on Vital and Health Statistics, an advisory body to the Department of Health and Human Services, has recommended adoption of specific operating rules to make financial/administrative electronic transactions more uniform.

The recommendations are important because the Accountable Care Act (health reform) mandates that health plans adopt operating rules. Payers have long adopted multiple voluntary HIPAA transactions standards but also implemented proprietary companion guides and payer sheets that require adherence to additional transaction implementation rules. Consequently, the HIPAA standards failed to make transactions considerably more uniform. Operating rules that payers can agree on are an attempt to "standardize the standards."

In a letter to HHS Secretary Kathleen Sebelius, NCVHS recommends Phases I and II of CORE operating rules covering eligibility and claim status transactions from CAQH, an alliance of payers and trade associations; and pharmacy-related operating rules from the National Council for Prescription Drug Programs.

While there are some regional initiatives to develop operating rules and some states have adopted their own set of operating rules, CAQH and NCPDP have over several years created rules that are gradually being voluntarily adopted on a national scale, with additional rules coming. If HHS accepts the NCVHS recommendations, those operating rules will be mandated.

More than 50 organizations have adopted Phase 1 CORE rules. Nineteen organizations, "which while not a large number of plans, does represent significant enrollment," according to NCVHS, are certified for Phase II rules. Under Phase III, new rules now are being developed for additional transactions.

NCVHS cautions HHS that the use of companion guides in coming years must be scrutinized. "NCVHS heard testimony concerning the continued of companion guides when operating rules are adopted," according to the letter of recommendations to HHS. "NCVHS does not wish to encourage the perpetual use of companion guides which subvert the adoption of standards. However, testifiers did indicate that companion guides may be necessary for transmission instructions and other limited business purposes."

Consequently, NCVHS recommends that HHS require any companion guides deemed necessary do not conflict with the standards, implementation specification and operating rules adopted by regulation. "Companion guides should be limited to providing basic trading partner facts, such as contact information, web sites, service phone numbers, etc.," according to the advisory body.

Text of the NCVHS letter of recommendations and accompanying attachments is available at ncvhs.hhs.gov/100930lt2.pdf.

--Joseph Goedert

 

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