Health Insurance Reform: Standards for Electronic Transactions. f. Transaction Standard for Eligibility for a Health Plan


In subpart P, redesignated in this rule as subpart L, we proposed the ASC X12N 270 - Health Care Eligibility/Benefit Inquiry and ASC X12N 271 - Health Care Eligibility/Benefit Response, Version 4010, Washington Publishing Company, (004010X092) as the standard for eligibility for a health plan.

Comments and Responses on the Transaction Standard for Eligibility for a Health Plan

The majority of commenters expressed support for the selected standard.

i. Of those comments we referred to ASC X12N, the work groups determined that 224 comments identified areas where the implementation specification could be improved, and the appropriate changes were made.

ii. Eleven comments identified business needs that ASC X12N judged could already be met within the current standard implementation specification. Detailed information on how the current implementation specifications can be used to meet these business needs has been provided by ASC X12N at the Internet site in §162.920.

iii. Seven comments alleged technical or editorial errors in the standard implementation specification. A technical review of these issues was conducted by work groups within ASC X12N. The work groups determined that the 7 comments identified areas where the implementation specifications were in fact correct and that no changes were needed. Changes to the implementation specification were not required.

iv. There were another 10 comments which identified business needs that ASC X12N judged could not be met directly within the current standard implementation specification. The implementation specifications could not be changed prior to the issuance of the final regulation because the X12 standards development process for modifying standards could not be completed in time. However, a review of the issues by the ASC X12N work groups has identified a means of meeting the business needs within the existing implementation specification as an interim measure. Organizations and individuals who submitted such comments are encouraged to work with the DSMOs to submit a request to modify the national standard.

v. Comment: We received one individual comment requesting changes to a set of codes which were not maintained by X12 or by a Federal agency, but were maintained by an external code source maintaining body.

Response: All code sources external to the X12 standard are listed in section C of the implementation specifications. All of these code sources have a mechanism for modifying their codes. The contact listed in the X12 code source list can provide detailed information regarding the process for updating their codes. The X12N subcommittee can also assist entities in determining how to contact an external code source maintenance body in order to request changes to the codes. Code sets not listed in the external code set appendices in the implementation specifications fall within X12N jurisdiction and are maintained through that organization’s data maintenance procedures, in conjunction with the DSMOs.

vi. Comment: Several commenters recommended that we include the NCPDP telecommunications Standard 3.2 for the pharmacy service sector eligibility inquiries. One commenter said that this is the only automated eligibility inquiry allowed for use by pharmacy providers. A commenter said that it uses the transaction (the NCPDP telecommunications Standard 3.2) for the pharmacy service sector for both claim and eligibility transactions. Finally, additional commenters suggested that there is no business need that should force health care providers to move to the ASC X12N 270/271 transaction for the pharmacy service sector for eligibility inquiries. It was stated that thousands of eligibility transactions are performed each month by pharmacies and health plans using the NCPDP telecommunications Standard 3.2. Furthermore, there is no benefit in moving to the ASC X12N 270/271 for pharmacy eligibility inquiries since the NCPDP telecommunications Standard 3.2 is already fully supported.

Response: We agree with the commenter that eligibility and enrollment are integral to the NCPDP Telecommunications Standard named in the proposed rule for retail pharmacy claims. We name the NCPDP Telecommunications Standard 5.1 and the NCPDP Batch Standard as the standard for patient eligibility and coverage information within the retail pharmacy sector since the eligibility information is part of the NCPDP standard. We have added this requirement to §162.1202.

vii. Comments: Several commenters suggested that the ASC X12N 270/271 Eligibility Roster implementation specification for eligibility for a health plan should be adopted as a HIPAA standard. One commenter suggested that the description of the roster implementation is incorrect in that it states that the roster is a separate part of the 270/271. The commenter went on to explain that the roster is essentially the same transaction as that being recommended for response to an X12N 270 inquiry, but the implementation specification has different values in some of the segments so that the X12N 271 response can be sent without an associated inquiry, and so that the hierarchy of benefits can be more fully described. It was also suggested that the example of a health plan sending the X12N 270/271 roster to alert a hospital about forthcoming admissions was not representative of the functionality of the roster. The commenter also stated that there are health care providers who currently use the X12N 270/271 electronic roster implementation, and it was misleading to use the term “not recommended” in connection with the roster implementation specification. Additionally, the commenter stated that it is incorrect to say that the roster implementation specification is not millennium compliant and that the standards development process for the implementation specification is not completed.

Response: We agree that a more precise description of the roster functionality would be to refer to it as another implementation rather than another part of the standard. Although the current version of this implementation specification is millennium compliant and complete, this was not true at the time the proposed rule was written. Thus, we did not recommend the use of the ASC X12N 270/271 to provide requests for eligibility. Another implementation of the ASC X12N 271 is designed to handle requests for eligibility “rosters,” which are essentially lists of entities -- subscribers and dependents, health care providers, employer groups, health plans -- and their relationships to each other. For example, this transaction might be used by a health plan to submit a roster of patients to a health care provider in order to designate a primary care physician.

The eligibility inquiry and response is the only implementation proposed under HIPAA for eligibility for a health plan. The implementation of the HIPAA standards will be a great undertaking and at this time we are limiting the transactions to those identified in the proposed rule. In addition, entities who move eligibility information in a roster format may do so using any available format, including the ASC X12N 270/271 roster implementation. After the implementation specification for the roster function is complete and approved by an accredited standard setting organization, we recommend that a request for adopting the new standard be submitted to the DSMOs. See §162.910 for the process to request new standards.

viii. Comment: Several commenters recommended that the Interactive Health Care Eligibility/Benefit Inquiry (IHCEBI) transaction set and its companion, the Interactive Health Care Eligibility/Benefit Response (IHCEBR) transaction set, should also be adopted.

Response: The IHCEBI/IHCEBR is based on UNEDIFACT syntax, not ASC X12N syntax. At the time of the development of the proposed rule, the syntax used was a version subsequently modified by UNEDIFACT, resulting in the need to reformat the messages into the modified syntax before they could be adopted by the UNEDIFACT body. Therefore, there was no uniform implementation specification developed for these standards. After consideration, we decided that, where possible, the transactions to be named in the proposed rule should have a uniform syntax structure. This was possible for all transactions; ASC X12N transactions were chosen because they met the criteria of having implementation specifications and having the same basic syntax structure. The NCPDP standards also met the criteria, and each transaction is designed using the same syntax structure. If, in the future, a millennium compliant interactive eligibility for a health plan transaction standard is approved by an ANSI accredited standards setting organization and an implementation specification exists, we shall consider it for adoption as a HIPAA standard.

ix. Comment: We received one comment that suggested we clarify that the eligibility response sent by a health plan is not the equivalent of a prior authorization of services, and does not guarantee coverage of a rendered service.

Response: We believe that the purpose and scope of the ASC X12N 270/271 is clearly defined in the ASC X12N 270/271 Health Care Eligibility Benefit Inquiry and Response implementation specification. An eligibility response sent by a health plan is not the equivalent of a prior authorization of services and does not guarantee coverage of a rendered service. Furthermore, the function of prior authorization of services is explicitly defined in the ASC X12N 278, Health Care Services Review - Request for Review and Response implementation specification, which is the recommended standard for this transaction.

x. Comment: One commenter suggested that we clarify the requirements to clearly state that while health plans must implement the ASC X12N 270/271 Eligibility Request/Response, they are not required to respond to all requests sent in the ASC X12N 270.

Response: We do not agree. A health plan may not reject a standard transaction because it contains information the health plan does not want. This principle applies to the data elements of all transactions in this rule. Health plans must accept a complete ASC X12N 270 and must respond with all applicable responses that are included in the ASC X12N 271. If health plans can arbitrarily respond or not respond to a standard transaction, then the cost saving effect of using the standards will be blunted by a requirement to negotiate aspects of every transaction with every trading partner.

xi. Comment: One commenter said that the ASC X12N 270 transaction requires an ASC X12N 271 response to every record, a one-to-one correspondence. The commenter recommended that the one-to-one response be negotiable between the parties that have a contract to exchange information.

Response: A one-to-one correspondence to every record is not required. The ASC X12N 270/271 transaction sets were built so that trading partners could use them in real time or batch mode. We agree that negotiation must occur between trading partners (including clearinghouses/switches) regarding the processing limits (i.e., file size, transmission speeds).