Health Insurance Reform: Standards for Electronic Transactions. h. Transaction Standard for Referral Certification and Authorization

10/16/2000

In subpart R, redesignated as subpart M, we proposed the ASC X12N 278 - Health Care Services Review--Request for Review and Response, Version 4010, Washington Publishing Company, (004010X094) as the standard for referral certifications and authorizations.

Comments and Responses on the Transaction Standard for Referral Certification and Authorization

The majority of commenters expressed support for the selected standard.

i. Of those comments we referred to ASC X12N, the work groups determined that 146 comments identified areas where the implementation specification could be improved, and the appropriate changes were made.

ii. Thirteen 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. Three 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 3 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 76 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: Several commenters requested that we need to make clear that if a state health agency does not authorize referrals it is not required to use the standard.

Response: If a state health agency does not conduct referral certification and authorization, then the health plan is not required to support this transaction based solely on the fact that the transaction is one named as a HIPAA transaction. However, we note that most commercially available software packages are designed to support a suite of transactions. We anticipate that vendors will offer suites for all HIPAA transactions, which may encourage health plans to support this specific transaction.

vi. Comment: Several commenters recommended that we include the Inquiry and Response and Notification implementations of the ASC X12N 278.

Response: The Request for Review and Response is the only implementation proposed under HIPAA for referral certification and authorization. We are not accommodating this request, because at the time of the development of the proposed rule, the standards development process for the ASC X12N Inquiry and Response and Notification implementation specifications was incomplete and not supported by an accredited standard setting organization. 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. Entities who use Inquiry and Response and Notification implementations may do so using any available format, including the ASC X12N 278 implementations until such time as we may adopt a standard for Inquiry and Response and Notification through regulation. After the implementation specification for these functions is complete and approved by an accredited standard setting organization, we encourage a request to test a proposed revision to the standard be submitted to the Secretary (see §162.940).