Questions Submitted by the Public, by Date Posted to the Website. When entities must conduct the standard transaction

11/02/2001

Where in the implementation guides is the definition that the eligibility for a health plan transaction is an inquiry from a health care provider to a health plan or from one health plan to another health plan. in the implementation guides? Can you clarify the criteria that determine when entities must conduct the transaction as a standard?

In the preamble of the Final Rule, item 6 "Exceptions for Transactions Within Corporate Entities," example 2 involves a large multi-state employer, seven insurance companies (TPAs) and one data service company. The example appears to be used to illustrate the criterion that determines when entities must comply with the electronic formats under HIPAA law. In this specific example, the conclusion is made that the eligibility inquiries from the TPAs to the data service center do not have to meet the requirements because, "...the inquiry is from one business associate of a health plan to another business associate of the same health plan. Therefore, the inquiry does not meet the definition of an eligibility for a health plan transaction, and is not required to be conducted as a standard transaction."

The conclusion that this example makes is that the definition of the transaction is not met by virtue of who was inquiring and who was responding (i.e., the inquiry was between two business associates of the same health plan). This would seem to establish a number of criteria for entities to use in determining whether entities are to conduct transactions using the standard.

The example states that the definition of the eligibility for a health plan transaction is an inquiry from a health care provider to a health plan or from one health plan to another health plan. Where is this definition in the implementation guides? Can you clarify the criteria that determine when entities must conduct the transaction as a standard?


7/1/2001:

The final rule did not create an exception for transactions within a "corporate entity." Instead, two criteria are to be used to determine whether a transaction must be conducted as a standard transaction.

First, is the entity conducting the transaction a covered entity?

Second, does the transaction meet the definition of one of the transactions defined in subparts K through R of part 162?

The transactions are described in the regulation itself rather than within the implementation guides. Since the TPAs are business associates of the health plan, the health plan must require them to follow the transactions rules that apply to it. However, since the transmission of the eligibility request is from the TPA to the data service center (business associate to business associate of the same health plan), it does not meet the definition of eligibility for a health plan transaction in 162.1201