NRPM: Standards for Electronic Transactions. List of Subjects in 45 CFR Part 142

05/07/1998

[Please label any written comments or e-mailed comments about this section with the subject: Reg Text]

Administrative practice and procedure, Health facilities, Health insurance, Hospitals, Incorporation by reference, Medicare, Medicaid.

Accordingly, 45 CFR subtitle A, subchapter B, would be amended by adding Part 142 to read as follows:

NOTE TO READER: This proposed rule and another proposed rule found elsewhere in this Federal Register are two of several proposed rules that are being published to implement the administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996. We propose to establish a new 45 CFR Part 142. Proposed Subpart A--General Provisions is exactly the same in each rule unless we have added new sections or definitions to incorporate additional general information. The subparts that follow relate to the specific provisions announced separately in each proposed rule. When we publish the first final rule, each subsequent final rule will revise or add to the text that is set out in the first final rule.

PART 142--ADMINISTRATIVE REQUIREMENTS

Subpart A--General Provisions

Sec.

142.101 Statutory basis and purpose.

142.102 Applicability.

142.103 Definitions.

142.104 General requirements for health plans.

142.105 Compliance using a health care clearinghouse.

142.106 Effective dates of a modification to a standard or implementation specification.

142.110 Availability of implementation guides.

Subparts B - I [RESERVED]

Subpart J - Code Sets

142.1002 Medical data code sets.

142.1004 Code sets for nonmedical data elements.

142.1010 Effective dates of the initial implementation of code sets.

Subpart K - Health Claims or Equivalent Encounter Information

142.1102 Standards for health claims or equivalent encounter information.

142.1104 Requirements: Health plans.

142.1106 Requirements: Health care clearinghouses.

142.1108 Requirements: Health care providers.

142.1110 Effective dates of the initial implementation of the health claim or equivalent encounter information.

Subpart L - Health Claims and Remittance Advice

142.1202 Standard for health care payment and remittance advice.

142.1204 Requirements: Health plans.

144.1206 Requirements: Health care clearinghouses.

142.1210 Effective dates of the initial implementation of the health claims and remittance advice.

Subpart M - Coordination of Benefits

142.1302 Standard for coordination of benefits.

142.1304 Requirements: Health plans.

144.1306 Requirements: Health care clearinghouses.

142.1308 Effective dates of the initial implementation of the standard for coordination of benefits.

Subpart N - Health Claim Status

142.1402 Standard for health claim status.

142.1404 Requirements: Health plans.

144.1406 Requirements: Health care clearinghouses.

142.1408 Requirements: Health care providers.

142.1410 Effective dates of the initial implementation of the standard for health claims status.

Subpart O - Enrollment and Disenrollment in a Health Plan

142.1502 Standard for enrollment and disenrollment in a health plan.

142.1504 Requirements: Health plans.

144.1506 Requirements: Health care clearinghouses.

142.1508 Effective dates of the initial implementation of the standard for enrollment and disenrollment in a health plan.

Subpart P - Eligibility for a Health Plan

142.1602 Standard for eligibility for a health plan.

142.1604 Requirements: Health plans.

144.1606 Requirements: Health care clearinghouses.

142.1608 Requirements: Health care providers.

142.1610 Effective dates of the initial implementation of the standard for eligibility for a health plan.

Subpart Q - Health Plan Premium Payments

142.1702 Standard for health plan premium payments.

142.1704 Requirements: Health plans.

144.1706 Requirements: Health care clearinghouses.

142.1708 Effective dates of the initial implementation of the standard for health plan premium payments.

Subpart R - Referral Certification and Authorization

142.1802 Referral certification and authorization.

142.1804 Requirements: Health plans.

144.1806 Requirements: Health care clearinghouses.

142.1808 Requirements: Health care providers.

142.1810 Effective dates of the initial implementation of the standard for referral certifications and authorizations.

Authority: Sections 1173 and 1175 of the Social Security Act (42 U.S.C. 1320d-2 and 1320d-4)

Subpart A--General Provisions

§ 142.101 Statutory basis and purpose.

Sections 1171 through 1179 of the Social Security Act, as added by section 262 of the Health Insurance Portability and Accountability Act of 1996, require HHS to adopt national standards for the electronic exchange of health information in the health information system. The purpose of these sections is to promote administrative simplification.

§ 142.102 Applicability.

(a) The standards adopted or designated under this part apply, in whole or in part, to the following:

(1) A health plan.

(2) A health care clearinghouse when doing the following:

(i) Transmitting a standard transaction (as defined in § 142.103) to a health care provider or health plan.

(ii) Receiving a standard transaction from a health care provider or health plan.

(iii) Transmitting and receiving the standard transactions when interacting with another health care clearinghouse.

(3) A health care provider when transmitting an electronic transaction as defined in § 142.103.

(b) Means of compliance are stated in greater detail in § 142.105.

§ 142.103 Definitions.

For purposes of this part, the following definitions apply:

ASC X12 stands for the Accredited Standards Committee chartered by the American National Standards Institute to design national electronic standards for a wide range of business applications.

ASC X12N stands for the ASC X12 subcommittee chartered to develop electronic standards specific to the insurance industry.

Code set means any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes.

Health care clearinghouse means a public or private entity that processes or facilitates the processing of nonstandard data elements of health information into standard data elements. The entity receives transactions from health care providers, health plans, other entities, or other clearinghouses, translates the data from a given format into one acceptable to the intended recipient, and forwards the processed transaction to the appropriate recipient. Billing services, repricing companies, community health management information systems, community health information systems, and “value-added” networks and switches are considered to be health care clearinghouses for purposes of this part.

Health care provider means a provider of services as defined in section 1861(u) of the Social Security Act, a provider of medical or other health services as defined in section 1861(s) of the Social Security Act, and any other person who furnishes or bills and is paid for health care services or supplies in the normal course of business.

Health information means any information, whether oral or recorded in any form or medium, that--

(1) Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and

(2) Relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual.

Health plan means an individual or group plan that provides, or pays the cost of, medical care. Health plan includes the following, singly or in combination:

(1) Group health plan. A group health plan is an employee welfare benefit plan (as currently defined in section 3(1) of the Employee Retirement Income and Security Act of 1974 (29 U.S.C. 1002(1)), including insured and self-insured plans, to the extent that the plan provides medical care, including items and services paid for as medical care, to employees or their dependents directly or through insurance, or otherwise, and

(i) Has 50 or more participants; or

(ii) Is administered by an entity other than the employer that established and maintains the plan.

(2) Health insurance issuer. A health insurance issuer is an insurance company, insurance service, or insurance organization that is licensed to engage in the business of insurance in a State and is subject to State law that regulates insurance.

(3) Health maintenance organization. A health maintenance organization is a Federally qualified health maintenance organization, an organization recognized as a health maintenance organization under State law, or a similar organization regulated for solvency under State law in the same manner and to the same extent as such a health maintenance organization.

(4) Part A or Part B of the Medicare program under title XVIII of the Social Security Act.

(5) The Medicaid program under title XIX of the Social Security Act.

(6) A Medicare supplemental policy (as defined in section 1882(g)(1) of the Social Security Act).

(7) A long-term care policy, including a nursing home fixed-indemnity policy.

(8) An employee welfare benefit plan or any other arrangement that is established or maintained for the purpose of offering or providing health benefits to the employees of two or more employers.

(9) The health care program for active military personnel under title 10 of the United States Code.

(10) The veterans health care program under 38 U.S.C., chapter 17.

(11) The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), as defined in 10 U.S.C. 1072(4).

(12) The Indian Health Service program under the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.).

(13) The Federal Employees Health Benefits Program under 5 U.S.C. chapter 89.

(14) Any other individual or group health plan, or combination thereof, that provides or pays for the cost of medical care.

Medical care means the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any body structure or function of the body; amounts paid for transportation primarily for and essential to these items; and amounts paid for insurance covering the items and the transportation specified in this definition.

Participant means any employee or former employee of an employer, or any member or former member of an employee organization, who is or may become eligible to receive a benefit of any type from an employee benefit plan that covers employees of that employer or members of such an organization, or whose beneficiaries may be eligible to receive any of these benefits. “Employee” includes an individual who is treated as an employee under section 401(c)(1) of the Internal Revenue Code of 1986 (26 U.S.C. 401(c)(1)).

Small health plan means a group health plan or individual health plan with fewer than 50 participants.

Standard means a set of rules for a set of codes, data elements, transactions, or identifiers promulgated either by an organization accredited by the American National Standards Institute or HHS for the electronic transmission of health information.

Transaction means the exchange of information between two parties to carry out financial and administrative activities related to health care. It includes the following:

(1) Transactions specified in section 1173(a)(2) of the Act, which are as follows:

(i) Health claims or equivalent encounter information.

(ii) Health care payment and remittance advice.

(iii) Health claims status.

(iv) Enrollment and disenrollment in a health plan.

(v) Eligibility for a health plan.

(vi) Health plan premium payments.

(vii) First report of injury.

(viii) Referral certification and authorization.

(ix) Health claims attachments.

(2) Other transactions as the Secretary may prescribe by regulation. Coordination of benefits is a transaction under this authority.

§ 142.104 General requirements for health plans.

If a person conducts a transaction (as defined in § 142.103) with a health plan as a standard transaction, the following apply:

(a) The health plan may not refuse to conduct the transaction as standard transaction.

(b) The health plan may not delay the transaction or otherwise adversely affect, or attempt to adversely affect, the person or the transaction on the basis that the transaction is a standard transaction.

(c) The health information transmitted and received in connection with the transaction must be in the form of standard data elements of health information.

(d) A health plan that conducts transactions through an agent must assure that the agent meets all the requirements of this part that apply to the health plan.

§ 142.105 Compliance using a health care clearinghouse.

(a) Any person or other entity subject to the requirements of this part may meet the requirements to accept and transmit standard transactions by either--

(1) Transmitting and receiving standard data elements, or

(2) Submitting nonstandard data elements to a health care clearinghouse for processing into standard data elements and transmission by the health care clearinghouse and receiving standard data elements through the health care clearinghouse.

(b) The transmission, under contract, of nonstandard data elements between a health plan or a health care provider and its agent health care clearinghouse is not a violation of the requirements of this part.

§ 142.106 Effective dates of a modification to a standard or implementation specification.

If HHS adopts a modification to a standard or implementation specification, the implementation date of the modified standard or implementation specification may be no earlier than 180 days following the adoption of the modification. HHS determines the actual date, taking into account the time needed to comply due to the nature and extent of the modification. HHS may extend the time for compliance for small health plans.

§ 142.110 Availability of implementation guides.

The implementation guides specified in subparts K through R of this part are available as set forth in paragraphs (a) through (c) of this section. Entities requesting copies or access for inspection must specify the standard by name, number, and version.

(a) The implementation guides for ASC X12 standards may be obtained from the Washington Publishing Company, 806 W. Diamond Ave., Suite 400, Gaithersburg, MD, 20878; telephone 301-590-9337; and FAX: 301-869-9460. They are also available, at no cost, through the Washington Publishing Company on the Internet at http://www.wpc-edi.com/hipaa/.

(b) The implementation guide for pharmacy claims may be obtained from the National Council for Prescription Drug Programs, 4201 North 24th Street, Suite 365, Phoenix, AZ, 85016; telephone 602-957-9105; and FAX 602-955-0749. It may also be obtained through the Internet at http://www.ncpdp.org.

(c) A copy of the guides may be inspected at the Office of the Federal Register, 800 North Capitol Street, NW, Suite 700, Washington, DC and at the Health Care Financing Administration.

Subparts B - I [RESERVED]

Subpart J - Code Sets

§ 142.1002 Medical data code sets.

Health plans, health care clearinghouses, and health care providers must use on electronic transactions the diagnostic and procedure code sets as prescribed by HHS. These code sets are published in a notice in the Federal Register. The implementation guides for the transaction standards in part 142, Subparts K through R specify which of the standard medical data code sets are to be used in individual data elements within those transaction standards.

§ 142.1004 Code sets for nonmedical data elements.

The code sets for nonmedical data that must be used in a transaction specified in subparts K through R of this part are the code sets described in the implementation guide for the transaction standard.

§ 142.1010 Effective dates of the initial implementation of code sets.

(a) Health plans. (1) Each health plan that is not a small health plan must comply with the requirements of §§ 142.104, 142.1002, and 142.1004 by [24 months after the effective date of the final rule in the Federal Register].

(2) Each small health plan must comply with the requirements of §§ 142.104, 142.1002, and 142.1004 by [36 months after the effective date of the final rule in the Federal Register].

(b) Health care clearinghouses and health care providers. Each health care clearinghouse and health care provider must begin to use the standards specified in §§ 142.1002 and 142.1004 by [24 months after the effective date of the final rule in the Federal Register].

Subpart K - Health Claims or Equivalent Encounter Information

§ 142.1102 Standards for health claims or equivalent encounter information.

The health claims or equivalent encounter information standards that must be used under this subpart are as follows:

(a) For pharmacy claims, the NCPDP Telecommunications Standard Format Version 3.2 and equivalent Standard Claims Billing Tape Format batch implementation, version 2.0. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(b) and (c) of this part.

(b) The ASC X12N 837 - Health Care Claim: Dental, Version 4010, Washington Publishing Company, 004010X097. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

(c) The ASC X12N 837 - Health Care Claim: Professional, Version 4010, Washington Publishing Company, 004010X098. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

(d) The ASC X12N 837 - Health Care Claim - Institutional, Version 4010, Washington Publishing Company, 004010X096. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

§ 142.1104 Requirements: Health plans.

Each health plan must accept the standard specified in § 142.1102 when conducting transactions concerning health claims and equivalent encounter information.

§ 142.1106 Requirements: Health care clearinghouses.

Each health care clearinghouse must use the standard specified in § 142.1102 when accepting or transmitting health claims or equivalent encounter information transactions.

§ 142.1108 Requirements: Health care providers.

Any health care provider that transmits health claims or equivalent encounter information electronically must use the standard specified in § 142.1102.

§ 142.1110 Effective dates of the initial implementation of the health claim or equivalent encounter information standard.

(a) Health plans. (1) Each health plan that is not a small health plan must comply with the requirements of §§ 142.104 and 142.1104 by [24 months after the effective date of the final rule in the Federal Register].

(2) Each small health plan must comply with the requirements of §§ 142.104 and 142.1104 by [36 months after the effective date of the final rule in the Federal Register].

(b) Health care clearinghouses and health care providers. Each health care clearinghouse and health care provider must begin to use the standard specified in § 142.1102 by [24 months after the effective date of the final rule in the Federal Register].

Subpart L - Health Claims and Remittance Advice

§ 142.1202 Standard for health claims and remittance advice.

The standard for health claims and remittance advice that must be used under this subpart is the ASC X12N 835 - Health Care Claim Payment/Advice, Version 4010, Washington Publishing Company, 004010X091. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

§ 142.1204 Requirements: Health plans.

Each health plan must transmit the standard specified in § 142.1202 when conducting health claims and remittance advice transactions.

§ 142.1206 Requirements: Health care clearinghouses.

Each health care clearinghouse must use the standard specified in § 142.1202 when accepting or transmitting health claims and remittance advice.

§ 142.1210 Effective dates of the initial implementation of the health claims and remittance advice.

(a) Health plans. (1) Each health plan that is not a small health plan must comply with the requirements of §§ 142.104 and 142.1204 by [24 months after the effective date of the final rule in the Federal Register].

(2) Each small health plan must comply with the requirements of §§ 142.104 and 142.1204 by [36 months after the effective date of the final rule in the Federal Register].

(b) Health care clearinghouses. Each health care clearinghouse must begin to use the standard specified in § 142.1204 by [24 months after the effective date of the final rule in the Federal Register].

Subpart M - Coordination of Benefits

§ 142.1302 Standard for coordination of benefits.

The coordination of benefits information standards that must be used under this subpart are as follows:

(a) For pharmacy claims, the NCPDP Telecommunications Standard Format Version 3.2 and equivalent Standard Claims Billing Tape Format batch implementation, version 2.0. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(b) and (c) of this part.

(b) For dental claims, the ASC X12N 837 - Health Care Claim: Dental, Version 4010, Washington Publishing Company, 004010X097. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

(c) For professional claims, the ASC X12N 837 - Health Care Claim: Professional, Version 4010, Washington Publishing Company, 004010X098. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

(d) For institutional claims, the ASC X12N 837 - Health Care Claim - Institutional, Version 4010, Washington Publishing Company, 004010X096. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

§ 142.1304 Requirements: Health plans.

Each health plan that performs coordination of benefits must accept and transmit the standard specified in § 142.1302 when accepting or transmitting coordination of benefits transactions.

§ 142.1306 Requirements: Health care clearinghouses.

Each health care clearinghouse must use the standard specified in § 142.1302 when accepting or transmitting coordination of benefits transactions.

§ 142.1308 Effective dates of the initial implementation of the standard for coordination of benefits.

(a) Health plans. (1) Each health plan that performs coordination of benefits and is not a small health plan must comply with the requirements of §§ 142.104 and 142.1304 by [24 months after the effective date of the final rule in the Federal Register].

(2) Each small health plan that performs coordination of benefits must comply with the requirements of §§ 142.104 and 142.1304 by [36 months after the effective date of the final rule in the Federal Register].

(b) Health care clearinghouses. Each health care clearinghouse must begin to use the standard specified in § 142.1302 by [24 months after the effective date of the final rule in the Federal Register].

Subpart N - Health Claim Status

§ 142.1402 Standard for health claim status.

The standard for health claim status that must be used under this subpart is the ASC X12N 276/277 Health Care Claim Status Request and Response, Version 4010, Washington Publishing Company, 004010X093. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

§ 142.1404 Requirements: Health plans.

Each health plan must accept and transmit the standard specified in § 142.1402 when accepting or transmitting health claim status in transactions with health care providers.

§ 142.1406 Requirements: Health care clearinghouses.

Each health care clearinghouse must use the standard specified in § 142.1402 when accepting or transmitting health claims status transactions.

§ 142.1408 Requirements: Health care providers.

Any health care provider that transmits or accepts health claims status electronically must use the standard specified in § 142.1402.

§ 142.1410 Effective dates of the initial implementation of the standard for health claims status.

(a) Health plans. (1) Each health plan that is not a small health plan must comply with the requirements of §§ 142.104 and 142.1404 by [24 months after the effective date of the final rule in the Federal Register].

(2) Each small health plan must comply with the requirements of §§ 142.104 and 142.1404 by [36 months after the effective date of the final rule in the Federal Register].

(b) Health care clearinghouses and health care providers. Each health care clearinghouse and health care provider must begin to use the standard specified in § 142.1402 by [24 months after the effective date of the final rule in the Federal Register].

Subpart O - Enrollment and Disenrollment in a Health Plan

§ 142.1502 Standard for enrollment and disenrollment in a health plan.

The standard for enrollment and disenrollment in a health plan that must be used under this subpart is the ASC X12 834 - Benefit Enrollment and Maintenance, [date], Version 4010, Washington Publishing Company, (004010X095). The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

§ 142.1504 Requirements: Health plans.

Each health plan must accept the standard specified in § 142.1502 when accepting transactions for enrollment and disenrollment in a health plan.

§ 142.1506 Requirements: Health care clearinghouses.

Each health care clearinghouse must use the standard specified in § 142.1502 when accepting or transmitting transactions for enrollment and disenrollment in a health plan.

§ 142.1508 Effective dates of the initial implementation of the standard for enrollment and disenrollment in a health plan.

(a) Health plans. (1) Each health plan that is not a small health plan must comply with the requirements of §§ 142.104 and 142.1504 by [24 months after the effective date of the final rule in the Federal Register].

(2) Each small health plan must comply with the requirements of §§ 142.104 and 142.1504 by [36 months after the effective date of the final rule in the Federal Register].

(b) Health care clearinghouses. Each health care clearinghouse must begin to use the standard specified in § 142.1502 by [24 months after the effective date of the final rule in the Federal Register].

Subpart P - Eligibility for a Health Plan

§ 142.1602 Standard for eligibility for a health plan.

The standard for eligibility for a health plan transaction that must be used under this subpart is ASC X12N 270 - Health Care Eligibility Benefit Inquiry and ASC X12N 271 - Health Care Eligibility Benefit Response, [date], Version 4010, Washington Publishing Company, (004010X092). The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

§ 142.1604 Requirements: Health plans.

Each health plan must accept and transmit the standard specified in § 142.1602 when accepting or transmitting transactions for eligibility for a health plan.

§ 142.1606 Requirements: Health care clearinghouses.

Each health care clearinghouse must use the standard specified in § 142.1602 when accepting or transmitting transactions for eligibility for a health plan.

§ 142.1608 Requirements: Health care providers.

Any health care provider that transmits or receives transactions for eligibility for a health plan electronically must use the standard specified in § 142.1602.

§ 142.1610 Effective dates of the initial implementation of the standard for eligibility for a health plan.

(a) Health plans. (1) Each health plan that is not a small health plan must comply with the requirements of §§ 142.104 and 142.1604 by [24 months after the effective date of the final rule in the Federal Register].

(2) Each small health plan must comply with the requirements of §§ 142.104 and 142.1604 by [36 months after the effective date of the final rule in the Federal Register].

(b) Health care clearinghouses and health care providers. Each health care clearinghouse and health care provider must begin to use the standard specified in § 142.1602 by [24 months after the effective date of the final rule in the Federal Register].

Subpart Q - Health Plan Premium Payments

§ 142.1702 Standard for health plan premium payments.

The standard for health plan premium payments that must be used under this subpart is the ASC X12 820 - Payment Order/Remittance Advice, [date], Version 4010, Washington Publishing Company, (004010X061). The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

§ 142.1704 Requirements: Health plans.

Each health plan must accept the standard specified in § 142.1702 when accepting electronically transmitted health plan premium payments.

§ 142.1706 Requirements: Health care clearinghouses.

Each health care clearinghouse must use the standard specified in § 142.1702 when accepting or transmitting health plan premium payments.

§ 142.1708 Effective dates of the initial implementation of the standard for health plan premium payments.

(a) Health plans. (1) Each health plan that is not a small health plan must comply with the requirements of §§ 142.104 and 142.1704 by [24 months after the effective date of the final rule in the Federal Register].

(2) Each small health plan must comply with the requirements of §§ 142.104 and 142.1704 by [36 months after the effective date of the final rule in the Federal Register].

(b) Health care clearinghouses. Each health care clearinghouse must begin to the use the standard specified in § 142.1702 by [24 months after the effective date of the final rule in the Federal Register].

Subpart R - Referral Certification and Authorization

§ 142.1802 Referral certification and authorization.

The standard for referral certification and authorization transactions that must be used under this subpart is the ASC X12N 278 - Request for Review and Response, [date], Version 4010, Washington Publishing Company, (004010X094). The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. The guide is available at the addresses specified in § 142.108(a) and (c) of this part.

§ 142.1804 Requirements: Health plans.

Each health plan must accept and transmit the standard specified in § 142.1802 when accepting or transmitting referral certifications and authorizations.

§ 142.1806 Requirements: Health care clearinghouses.

Each health care clearinghouse must use the standard specified in § 142.1902 when accepting or transmitting referral certifications and authorizations.

§ 142.1808 Requirements: Health care providers.

Any health care provider that transmits or accepts referral certifications and authorizations electronically must use the standard specified in § 142.1902.

§ 142.1810 Effective dates of the initial implementation of the standard for referral certifications and authorizations.

(a) Health plans. (1) Each health plan that is not a small health plan must comply with the requirements of §§ 142.104 and 142.1804 by [24 months after the effective date of the final rule in the Federal Register].

(2) Each small health plan must comply with the requirements of §§ 142.104 and 142.1804 by [36 months after the effective date of the final rule in the Federal Register].

(b) Health care clearinghouses and health care providers. Each health care clearinghouse and health care provider must begin to use the standard specified in § 142.1802 by [24 months after the effective date of the final rule in the Federal Register].

Authority: Sections 1173 and 1175 of the Social Security Act (42 U.S.C. 1320d-2 and 1320d-4)


Dated:

Donna E. Shalala
Secretary.

BILLING CODE 4120-01-P