Questions Submitted by the Public, by Date Posted to the Website. Distinction between health plan and clearinghouse


Can a health plan act as both a health plan and a health care clearinghouse, allowing their health care providers to continue to send non-standard since they say they will translate them to standard prior to sending to their internal system? If so, how will anyone know if they truly translate the non-standard to standard?


The definition of a health care clearinghouse in 160.103 includes the receipt and sending of transactions from and to "another entity." If the "other entity" is itself a health plan, then it cannot also be a health care clearinghouse. Therefore, if a health plan declares it is a health care clearinghouse, the health care clearinghouse would have to be outside of the health plan (i.e., not a component entity of the health plan) and there would have to be a business associate contract between the health plan and the health care clearinghouse in order that the health care clearinghouse transmits non-standard transactions to the health plan. The health plan is still obligated to have the capability to accept and send standard transactions.