Health Insurance Reform: Standards for Electronic Transactions. 7. Transaction


Comment: Several commenters recommended we amend the transaction definition to clarify each transaction.

Response: We have provided clarification in the definitions of each transaction in subparts K through R.

Additional Definitions

Comment: We received comments requesting that we define the terms “sponsor,” “third party administrator,” “trading partner agreement,” and “health claims attachments.”

Response: We have included a definition for trading partner agreement in §160.103. In this final rule, we are defining only terms used in the regulations text, therefore, we are not providing definitions for “sponsor” or “third party administrator.” In the future, we intend to publish a proposed rule that defines health claims attachment.

We have added definitions to parts 160 and 162 that were not part of the proposed rule. In order to clarify the applicability and scope of this rule, we have added definitions for “covered entity,” “trading partner agreement,” and “workforce” to part 160, and definitions for “direct data entry” and “electronic media” to part 162.

We have added a definition for “business associate” to part 160 in order to distinguish those functions a covered entity chooses other entities to perform on its behalf (making the other entity a business associate of the covered entity) from the functions of other types of agents. These other types may have differing meanings in different situations (for example, insurance agent).

To aid in the articulation of the process by which standards are adopted and changed, we have added definitions for “compliance date,” “implementation specification,” “modify” and “standard setting organization” to part 160, and definitions for “code set maintaining organization,” “designated standard maintenance organization (DSMO),” and “maintenance” to part 162.

We added a definition for “standard transaction” to part 162 to complement the definitions of “standard” and “transaction,” which were proposed and, in the case of standard, revised as discussed earlier in this preamble. And, in order to enumerate as many facets of a standard transaction as possible, we have added definitions for “data condition,” “data content,” “data element,” “data set,” “descriptor,” “format,” “maximum defined data set,” and “segment” to part 162. These definitions should help to make clear the components of a standard transaction.

We also made several clarifications with respect to the definition of “health plan” (§160.103). For purposes of defining the various health plans that are considered health plans for purposes of the regulation, we added the word “issuer” to Medicare supplemental policy, and long-term care policy. We included the word "issuer" when referring to long-term care policies, because policies themselves are not entities subject to the statute. Rather, it is the issuers of long-term care policies that are subject to the statute. We also added the SCHIP program, because it is a health plan under section 4901 of the Balanced Budget Act of 1997 (Public Law 105-33) and meets the statutory criteria for a health plan.

We are adding a definition of “state” to §160.103 to clarify its meaning with regard to the Federal programs included in the definition of “health plan,” which contain this term.

Several terms were in the proposed rule but are not included in the final rule. We have reconsidered the inclusion of the definition of “medical care.” It has come to our attention that the term “medical care” is easily confused with the term “health care.” Since the term medical care is used in the regulation only in the context of the definition of health plan and its inclusion in the regulation text may cause confusion, we have decided to remove the definition of “medical care” from the final regulation. We note, however, that “medical care” is a statutorily defined term and its use is critical in making a determination as to whether a health plan is considered a “health plan” for purposes of Administrative Simplification. Thus, we do include the statutory cite for “medical care” in the definitions of “group health plan” and “health plan.”

Similarly, we removed the definition of “participant” because it appears only in the context of the definitions of the various types of health plans. As in the case of “medical care,” we embed the statutory cite for the definition of “participant” in the definition of “group health plan.”

Also, the definitions for “ASC X12,” “ASC X12N” were removed because we decided their presence in the regulation did not add to the functionality of the text. We did not receive any comments on the definitions that were removed.