Refoem RoadMap

Health care reform

Because administrative costs contribute 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). A goal of administrative simplification is to improve the efficiency and effectiveness of the health care system through electronic transactions. Controlling health plans 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 Council for Affordable Qualilty Healthcare (CAQH®) Committee on Operating Rules for Information Exchange (CORE®) requirements (among other conditions).

CORE certification

Humana has achieved the Phase IV CAQH® Committee on Operating Rules for Information Exchange (CORE®) Phase IV Certification Seal.

The CORE Certification Seal was awarded after Humana successfully completed a thorough and independent testing process and a subsequent application review. This ensures that providers can gain access to consistent and accurate electronic administrative data, such as claims acknowledgments and prior authorization, from health plans following a common set of national operating rules.  

To find out more about CAQH CORE, visit www.caqhcore.org.

Health plan identifier (HPID)

On Oct. 31, 2014, the Centers for Medicare & Medicaid Services (CMS) Office of E-Health Standards and Services announced a delay in the enforcement of 45 CFR 162, Subpart E, the regulations pertaining to health plan enumeration and use of the 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, an advisory body to 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: https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Unique-Identifier/HPID.html (link opens in new window).

Related resources

Health care exchanges

Health care exchanges are mandated by the Affordable Care Act. They 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:
cciio.cms.gov/resources/factsheets/index.html (link opens in new window).

HIPAA guidelines

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