Health Insurance Reform: Standards for Electronic Transactions. d. Transaction Standard for Health Care Claim Status

10/16/2000

In subpart N, we proposed the ASC X12N 276/277 Health Care Claim Status Request and Response, Version 4010, Washington Publishing Company, 004010X093 as the standard for health care claim status.

Comments and Responses on the Transaction Standard for Health Care Claim Status

The majority of commenters expressed support for the selected standard.

i. Of those comments we referred to ASC X12N, the work groups determined that all 94 comments identified areas where the implementation specification could be improved, and the appropriate changes were made.

ii. Comment: We received several comments questioning whether the ASC X12N 277 “Unsolicited Claims Status Request” transaction will be included as a HIPAA standard transaction.

Response: The HIPAA transaction requirements do not include the ASC X12N 277 “Unsolicited Claims Status Request.” We expect to consider this transaction for adoption in a future regulation.

iii. Comment: Several commenters questioned whether a health care provider is mandated to use the ASC X12N 276 Health Care Claim Status Request transaction.

Response: A health care provider must use the ASC X12N 276 Health Care Claim Status Request transaction when transmitting the transaction electronically to a health plan. The health care provider has the option to submit nonstandard transactions to a health care clearinghouse for processing into the standard transaction and may of course choose to submit transactions in paper form.

iv. Comment: Several commenters questioned whether a health plan will be required to respond to an ASC X12N 276 request from a health care provider who did not have a business arrangement with the health plan.

Response: A health plan may not refuse to process a transaction simply because it is a standard transaction. Whether a health plan may refuse to process a transaction on other grounds may depend upon the particular business agreements the health plan has with the sender. Health plans may have contracts that require them to process out of service area transactions. Use of a standard transaction does not create a relationship or liability that does not otherwise exist. A health plan would not be required by these rules to respond to such a request from a health care provider with whom it does not have a business arrangement.

v. Comment: We received several comments relating to whether a State or health plan will be required to support the ASC X12N 276/277 transactions if they are currently using another application to provide this information.

Response: All health plans, including state Medicaid plans, must have the capability to accept, process, and send the ASC X12N 276/277 transactions.