Health Insurance Reform: Standards for Electronic Transactions. a. Affected Entities


Most health care providers that are currently using an electronic format for claim status inquiries (of which there are currently very few) and that wish to request claim status electronically using the ASC X12N 276/277 will incur conversion costs. We cannot quantify the number of health care providers that will have to convert to the standard, but we do know that no Medicare contractors use the standard; thus, we assume that few health care providers are able to use it at this time.

After implementation, health care providers will be able to request and receive the status of claims in one standard format from all health care plans. This will eliminate their need to maintain redundant software and will make electronic claim status requests and receipt of responses feasible for small health care providers, eliminating their need to manually send and review claim status requests and responses.

Health plans that do not currently directly accept electronic claim status requests and do not directly send electronic claims status responses will have to modify their systems to accept the ASC X12N 276 and to send the ASC X12N 277. No disruptions in claims processing or payment should occur.

After implementation, health plans will be able to submit claim status responses in one standard format to all health care providers. Administrative costs incurred by supporting multiple formats and manually responding to claim status requests will be greatly reduced.