Frequently Asked Questions About Electronic Transaction Standards Adopted Under HIPAA. Can health plans require changes or additions to the standard claim?

09/08/2000

Currently, some insurers accept the de facto standard claim (e.g., UB-92) but also require additional records (e.g., a proprietary cover sheet) for each claim submitted. Others have special requirements for data entered into the claim which make it non-standard.

Under the law, health plans are required to accept the standard claim submitted electronically. They may not require providers to make changes or additions to the standard claim. They must go through the private sector standards setting process to get their requirements added to the standard in order to effect desired changes. Health plans may not refuse the standard transaction or delay payment of a proper standard transaction.

An additional standard will be adopted for electronic health claims attachments, which health plans will be required also to accept. Until that standard is adopted (by February, 2001), health plans may continue to require health claim attachments to be submitted on paper. No other additions to standard claims will be acceptable.