Health Insurance Reform: Standards for Electronic Transactions. 5. Role of Health Care Clearinghouses


Proposal Summary: Health care clearinghouses would be able to accept nonstandard transactions for the sole purpose of translating them into standard transactions for sending customers and would be able to accept standard transactions and translate them into nonstandard formats for receiving customers (63 FR 25276).

Comment: Several commenters believe health care clearinghouses are excepted from accepting the standards. Other commenters believe that allowing health care providers to use a health care clearinghouse will negate administrative simplification. There was also concern that entities may designate themselves as a health care clearinghouse to avoid compliance.

Several commenters also requested that we clarify who is responsible for health care clearinghouse costs and state that contracts cannot require health care providers to use nonstandard formats.

Response: First, we clarify that a health care clearinghouse is a covered entity and must comply with these rules. Accordingly, all transactions covered by this part between health care clearinghouses must be conducted as standard transactions. However, the statute permits a covered entity to submit nonstandard communications to a health care clearinghouse for processing into standard transactions and transmission by the health care clearinghouse as well as receive standard transactions through the health care clearinghouse.

If a covered entity (for example, a health care provider) uses a health care clearinghouse to submit and receive nonstandard/standard transactions, the health care clearinghouse is the covered entity’s business associate. If a health plan operates as a health care clearinghouse, or requires the use of a health care clearinghouse, a health care provider may submit standard transactions to that health plan through the health care clearinghouse. However, the health care provider must not be adversely affected, financially or otherwise, by doing so. (For example, the costs of submitting a standard transaction to a health plan’s health care clearinghouse must not be in excess of the costs of submitting a standard transaction directly to the health plan.)

In §162.915, we clarify what a trading partner agreement that a covered entity enters into may not do. Section 162.923 specifies that a covered entity conducting a transaction covered under this rule with another covered entity (or within the same covered entity) using electronic media must conduct the transaction as standard transaction, with an exception for direct data entry. Section 162.925 makes it clear that a health plan may not offer an incentive for a health care provider to conduct a transaction covered by this part under the direct data entry exception.