Health Insurance Reform: Standards for Electronic Transactions. c. Transaction Standard for Coordination of Benefits

10/16/2000

In subpart M, redesignated in this rule as subpart R, we proposed as the standards for coordination of benefits the following:

For pharmacy claims, the NCPDP Telecommunications Standard Format Version 3.2 and equivalent Standard Claims Billing Tape Format batch implementation, version 2.0.

For dental claims, the ASC X12N 837 - Health Care Claim: Dental, Version 4010, Washington Publishing Company, 004010X097.

For professional claims, the ASC X12N 837 - Health Care Claim: Professional, Version 4010, Washington Publishing Company, 004010X098.

For institutional claims, the ASC X12N 837 - Health Care Claim: Institutional, Version 4010, Washington Publishing Company, 004010X096.

Comments and Responses on the Transaction Standard for Coordination of Benefits: Pharmacy

Comment: One commenter suggested that the final rule contain the correct version of the NCPDP Batch Standard Version. The correct version is 1.0, not version 2.0 as originally proposed.

Response: We agree to make the recommended change for the batch standard. The proposed version 2.0 was incorrect. The correct name of the standard may be found in §162.1802. We are also changing the version to the NCPDP Telecommunications Standard Format Version for COB. The version is 5.1 as previously discussed.

Comments and Responses on the Transaction Standard for Coordination of Benefits: Dental, Professional, Institutional

i. Comment: One commenter recommended that claim/encounter data items should be distinguished from those data items that are part of the COB transaction process.

Response: One implementation specification is used for claims and coordination of benefits. The implementation specification clearly distinguishes between coordination of benefits data and claim data. For example, each coordination of benefits data element contains notes specifying when a particular data element is used.

ii. Comment: The majority of commenters supported the selection of the ASC X12N 837 for the coordination of benefits exchange standard. Some commenters believe that the decision to conduct COB in a certain manner is a business decision and not within the scope of HIPAA. Others would like all health plans to be required to participate in COB exchange using the plan to plan model in which the health care provider supplies the primary insurer with information needed for the primary insurer to then submit the claim directly to the secondary insurer. Several commenters stated that the plan to plan model would be quite costly and should be closely evaluated before being adopted at a national level.

Concern was expressed that if the standard COB transaction were sent to a health plan that does not conduct COB transactions, the health plan would reject the standard COB transaction because it contained COB information.

Response: Coordination of Benefits can be accomplished in two ways, either between health plans and other payers (for example, an auto insurance company), or from a health care provider to a health plan or other payer. The choice of model is up to the health plan.

Under this rule health plans are only required to accept COB transactions from other entities, including those that are not covered entities, with which they have trading partner agreements to conduct COB. Once such an agreement is in place, a health plan may not refuse to accept and process a COB transaction on the basis that it is a standard transaction. For example, a health plan receives a standard ASC X12N 837 transaction from a health care provider with which it has a COB trading partner agreement. If the health plan is not the primary payer, it must accept and process the COB information to adjudicate the claim. If the health plan has decided to conduct COB transactions with another payer, it must accept and store the COB information to use in a COB transaction with the other payer. If the health plan is the primary payer and does not have a trading partner agreement with the secondary payer, then it may simply dispose of the COB information and leave the COB activity up to the health care provider.

If a health plan electronically conducts COB with another health plan it must do so using the standard transaction. A health care provider that chooses to conduct COB electronically with a health plan must do so using the standard transaction. A COB transmission between a health care provider and a payer that is not a health plan would not be subject to the requirements of this rule; nor would the transmission of a COB transaction from a health plan to another payer that is not another health plan.