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Health Plan Certification

Background

In March 2010, HIPAA Administrative Simplification provisions were amended through the enactment of the Patient Protection and Affordable Care Act (ACA). Section 1104 of the ACA established new requirements for administrative transactions that will improve the utility of the existing HIPAA transactions and reduce administrative costs.

Specifically, Section 1104 of the ACA mandates a certification process for health plans. On January 2, 2014, the United States Department of Health and Human Services (DHHS) issued a Notice of Proposed Rulemaking (NPRM) on the ACA-mandated health plan certification process.
 
This rule proposes that controlling health plans (CHPs) submit certification documentation by the compliance date of December 31, 2015, that demonstrates compliance with the adopted standards and operating rules for three electronic transactions already required by HIPAA:

  • eligibility for a health plan
  • health care claim status
  • health care electronic funds transfers (EFT) and remittance advice

 

The Department of Health Care Services (DHCS) is committed to implementing the administrative simplification provisions of HIPAA, including the health plan certification requirements. DHCS will continue to monitor federal actions in this area, including release of a final health plan certification rule. DHCS will assess the impacts on DHCS systems and business processes and plan for changes accordingly.

Impacts

DHCS Health Plan trading partners, systems, and DHCS business processes.

Resources

Affordable Care Act

CAQH CORE

Federal Register

 

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Last modified on: 3/16/2016 10:44 AM