If a health care provider electronically conducts a non-compliant transaction (transmits an old National Standard Format or a proprietary format) directly to a health plan after the transaction regulation compliance date, and the health plan accepts and processes the non-compliant transaction, who is in violation of the regulation? Is it the health care provider or the health plan?
Does the acceptance and processing of a non-compliant transaction by a health plan from a health care provider constitute a violative trading partner agreement between the health plan and the health care provider?
If a health care provider electronically conducts a non-standard transaction with a health plan after the transaction regulation compliance date, the health care provider and the health plan are both out of compliance. Section 162.923(a) of the rule requires a covered entity conducting an electronic transaction for which a standard has been adopted with another covered entity to conduct it as a standard transaction.
If the health plan by agreement required the health care provider to conduct non-standard electronic transactions, such agreement would not by its terms violate section 162.915. However, if either party were to abide by the agreement, they would be out of compliance with section 162.923(a), for the reason stated above.