Refoem RoadMap

Health care reform

Because administrative costs are one factor that contributes to the high cost of health care, administrative simplification was included in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) by the U.S. Department of Health and Human Services (HHS). The goal of administrative simplification is to improve the efficiency and effectiveness of the health care system through electronic transactions. Controlling health plans (CHPs) must comply with the adopted standards and operating rules set forth by administrative simplification. Compliance can be achieved by demonstrating conformity with each of the CAQH Committee on Operating Rules (CORE) requirements (among other conditions).

CORE certification

Humana has received each of the CAQH CORE Information Exchange Certification seals.

These CORE certifications signify Humana's commitment to:

  • Improve access to patient insurance eligibility and benefit information.
  • Standardize the enrollment process for electronic funds transfer (EFT) and electronic remittance advice (ERA).
  • Deliver an industry-uniform use of claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs)
  • Support critical privacy and security practices.
Clinicians and other health care providers who want to learn how CORE operating rules will affect them can visit this CORE Web page for more information.

Health plan identifier (HPID)

On Oct. 31, 2014, the Centers for Medicare & Medicaid Services (CMS) Office of E-Health Standards and Services (OESS) announced a delay in the enforcement of 45 CFR 162, Subpart E, the regulations pertaining to health plan enumeration and use of the health plan identifier (HPID) in HIPAA transactions adopted in the HPID final rule (CMS-0040-F). This enforcement delay applies to all HIPAA-covered entities, including clinicians and other health care providers, health plans and health care clearinghouses.

On Sept. 23, 2014, the National Committee on Vital and Health Statistics (NCVHS), an advisory body to the Department of Health & Human Services (HHS), recommended that HHS rectify in rulemaking that all covered entities (health plans, clinicians and other health care providers and clearinghouses and their business associates) not use the HPID in HIPAA transactions.

For more information on health plan identifiers, go to: http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/Health-Plan-Identifier.html.

Related Resources

Health care exchanges

Health care exchanges are mandated by the Affordable Care Act (ACA) and are to be managed at the state level to offer basic health benefit plans to people who are not part of a group and don’t have other coverage available to them. For more information, visit this CMS website:
http://cciio.cms.gov/resources/factsheets/index.html.

HIPAA guidelines

For more information about HIPAA guidelines, visit
https://www.humana.com/provider/support/hipaa/.