Humana Healthcare Reform Roadmap

The Health Insurance Portability and Accountability Act (HIPAA) mandates certain transaction types for electronically submitted claims. These standards are used to help improve the quality of patient care, claim processing and data reporting.

Humana has received the Committee on Operating Rules for Information Exchange (CORE) Phase II Certification seal. This CORE certification was awarded upon completion of both Phase I and Phase II certification processes. Obtaining Core Phase II certification signifies Humana's commitment to health care providers to improve access to patient insurance eligibility and benefit information before or at the time of service. Additionally, all CORE Operating Rules support critical privacy and security practices.

What's Coming?

What's Coming
Effective Date
Effective date for operating rules for eligibility for health plan and health claims status transactions:
  • Eligibility Inquiry and Response (270 – 271)
  • Claim Status Inquiry and Response (276 – 277)
January 1, 2013
Certification, Part 1 – Health plan must certify data and information systems are in compliance with applicable standards and operating rules for:
  • Eligibility for a health plan
  • Health claim status
  • Electronic funds transfer
  • Health care payment and remittance advice
December 31, 2013
Effective date of operating rules for:
  • Electronic Remittance Advice (835)
  • Electronic Funds Transfer (EFT)
January 1, 2014
Effective date of ICD-10 CM and ICD-10 PCS October 1, 2014
Penalties may be assessed against a health plan that has failed to meet the certification and compliance requirements for standards and operating rules. April 1, 2015
Certification, Part 2 – Health plan must certify that its data and information systems are in compliance with applicable standards and operating rules for:
  • Health claims or equivalent encounter information
  • Enrollment and disenrollment in a health plan
  • Health plan premium payments
  • Referral certification and authorization
  • Health claims attachments
December 31, 2015
Effective Date of operating rules for:
  • Health claims or equivalent encounter information
  • Enrollment and disenrollment in a health plan
  • Health plan premium payments
  • Referral certification and authorization
  • Health care claims attachments
  • Claims and Encounters (837)
  • Referral Authorizations (278)
  • Premium Payment (820)
  • Claims Attachment (824)
  • Benefit Enrollment (834)
January 1, 2016

 

Definitions:

  • 270/271 Transaction: HIPAA-compliant electronic transaction that requests patient eligibility status (270) from Humana and returns current Humana membership status to the health care provider (271)
  • 276/277 Transaction: HIPAA-compliant transaction through which the health care provider requests the status of a submitted claim (276) and Humana responds with specific information about where it is in processing
  • 278: Under HIPAA regulation standards for electronic transactions, the referral certification and authorization are any of the following transmissions:
    1. A request for the review of health care to obtain an authorization for the health care
    2. A request to obtain authorization for referring an individual to another heath care provider
    3. A response to a request described in (a) or (b)
  • 834: Under HIPAA regulation standards for electronic transactions, the 834 is the transmission of subscriber enrollment information to a health plan to establish or terminate insurance coverage.
  • 835 Transaction: HIPAA-compliant ERA sent by Humana to health care providers explaining how a claim was paid.
  • EFT: Electronic Fund Transfer - Direct payment of a claim from Humana's bank account to the health care provider's bank account. This is similar to a wire transfer or online bill-pay systems for individual banking customers.
  • 837 Transaction: HIPAA-compliant electronic claim transaction sent by a health care provider to Humana for processing and payment.
  • 820: Transmission of premium payment information

Health plan identification

A final rule was announced on August 24, 2012, by the Department of Health and Human Services (HHS) to adopt a standard for a national unique health plan identifier (HPID) and a data element that will serve as an “other entity” identifier (OEID). This is an identifier for entities that are not health plans, health care providers or individuals, but that need to be identified in standard transactions. The rule also specifies the circumstances under which an organization-covered health care provider, such as a hospital, must require certain noncovered individual health care providers who are prescribers to obtain and disclose a National Provider Identifier (NPI).

The final rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to adopt standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OESS is part of the Centers for Medicare & Medicaid Services (CMS). The adoption of the HPID implements an administrative simplification provision of the Affordable Care Act (ACA).

The final rule announced adopts the standard for a national unique HPID and a data element that will serve as an OEID.

Related Resources

The final rule, CMS-0040-F, may be viewed at www.ofr.gov/inspection.aspx.

A news release on the final rule may be viewed at http://www.hhs.gov/news and http://www.cms.gov/apps/media/press_releases.asp.

OESS

CMS’ Office of E-Health Standards and Services is the U.S. Department of Health and Human Services’ component that enforces compliance with HIPAA transaction and code set standards.

Health Care Exchanges

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

Healthcare Reform

For more information on other Healthcare Reform topics visit Humana’s Healthcare Reform site. Here you will find a Timeline of Key Provisions
https://www.humana.com/learning-center/healthcare-reform/provisions

HIPAA

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

Key Provisions Timeline:

https://www.humana.com/learning-center/healthcare-reform/provisions