Sec. 613. Administrative simplification
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Section 1171 of the Social Security Act ( 42 U.S.C. 1320d ) is amended by adding at the end the following: The term operating rules means the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications as adopted for purposes of this part. . Section 1173 of the Social Security Act ( 42 U.S.C. 1320d–2 ) is amended— in subsection (a)(2), by adding at the end the following new subparagraph:
Electronic funds transfers. ; and by adding at the end the following new subsections: The Secretary shall adopt a single set of operating rules for each transaction described in subsection (a)(2) with the goal of creating as much uniformity in the implementation of the electronic standards as possible. Such operating rules shall be consensus-based and reflect the necessary business rules affecting health plans and health care providers and the manner in which they operate pursuant to standards issued under Health Insurance Portability and Accountability Act of 1996.
In adopting operating rules under this subsection, the Secretary shall rely on recommendations for operating rules developed by a qualified nonprofit entity, as selected by the Secretary, that meets the following requirements: The entity focuses its mission on administrative simplification. The entity demonstrates an established multi-stakeholder and consensus-based process for development of operating rules, including representation by or participation from health plans, health care providers, vendors, relevant Federal agencies, and other standard development organizations.
The entity has established a public set of guiding principles that ensure the operating rules and process are open and transparent. The entity coordinates its activities with the HIT Policy Committee and the HIT Standards Committee (as established under title XXX of the Public Health Service Act) and complements the efforts of the Office of the National Healthcare Coordinator and its related health information exchange goals. The entity incorporates national standards, including the transaction standards issued under Health Insurance Portability and Accountability Act of 1996.
The entity supports nondiscrimination and conflict of interest policies that demonstrate a commitment to open, fair, and nondiscriminatory practices. The entity allows for public review and updates of the operating rules. The National Committee on Vital and Health Statistics shall— review the operating rules developed by a nonprofit entity described under paragraph (2); determine whether such rules represent a consensus view of the health care industry and are consistent with and do not alter current standards; evaluate whether such rules are consistent with electronic standards adopted for health information technology; and submit to the Secretary a recommendation as to whether the Secretary should adopt such rules.
The Secretary shall adopt operating rules under this subsection, by regulation in accordance with subparagraph (C), following consideration of the rules developed by the non-profit entity described in paragraph
(2)and the recommendation submitted by the National Committee on Vital and Health Statistics under paragraph (3)(D) and having ensured consultation with providers. The set of operating rules for transactions for eligibility for a health plan and health claim status shall be adopted not later than July 1, 2015, in a manner ensuring that such rules are effective not later than January 1, 2017, and may allow for the use of a machine readable identification card. The set of operating rules for electronic funds transfers and health care payment and remittance advice shall be adopted not later than July 1, 2016, in a manner ensuring that such rules are effective not later than January 1, 2018. The set of operating rules for the remainder of the completed transactions described in subsection (a)(2), including health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, and referral certification and authorization, shall be adopted not later than July 1, 2018, in a manner ensuring that such rules are effective not later than January 1, 2020. The Secretary shall promulgate an interim final rule applying any standard or operating rule recommended by the National Committee on Vital and Health Statistics pursuant to paragraph (3). The Secretary shall accept public comments on any interim final rule published under this subparagraph for 60 days after the date of such publication. Not later than December 31, 2017, a health plan shall file a statement with the Secretary, in such form as the Secretary may require, certifying that the data and information systems for such plan are in compliance with any applicable standards (as described under paragraph
(7)of section 1171) and operating rules (as described under paragraph
(9)of such section) for electronic funds transfers, eligibility for a health plan, health claim status, and health care payment and remittance advice, respectively. Not later than December 31, 2019, a health plan shall file a statement with the Secretary, in such form as the Secretary may require, certifying that the data and information systems for such plan are in compliance with any applicable standards and operating rules for the remainder of the completed transactions described in subsection (a)(2), including health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, and referral certification and authorization, respectively. A health plan shall provide the same level of documentation to certify compliance with such transactions as is required to certify compliance with the transactions specified in subparagraph (A). A health plan shall provide the Secretary, in such form as the Secretary may require, with adequate documentation of compliance with the standards and operating rules described under paragraph (1). A health plan shall not be considered to have provided adequate documentation and shall not be certified as being in compliance with such standards, unless the health plan— demonstrates to the Secretary that the plan conducts the electronic transactions specified in paragraph
(1)in a manner that fully complies with the regulations of the Secretary; and provides documentation showing that the plan has completed end-to-end testing for such transactions with their partners, such as hospitals and physicians. A health plan shall be required to comply with any applicable certification and compliance requirements (and provide the Secretary with adequate documentation of such compliance) under this subsection for any entities that provide services pursuant to a contract with such health plan. The Secretary may contract with an independent, outside entity to certify that a health plan has complied with the requirements under this subsection, provided that the certification standards employed by such entities are in accordance with any standards or rules issued by the Secretary. A health plan (including entities described under paragraph (3)) shall comply with the certification and documentation requirements under this subsection for any interim final rule promulgated by the Secretary under subsection
(i)that amends any standard or operating rule described under paragraph
(1)of this subsection. A health plan shall comply with such requirements not later than the effective date of the applicable interim final rule. The Secretary shall conduct periodic audits to ensure that health plans (including entities described under paragraph (3)) are in compliance with any standards and operating rules that are described under paragraph (1). Not later than January 1, 2018, the Secretary shall establish a review committee (as described under paragraph (4)). Not later than April 1, 2018, and not less than biennially thereafter, the Secretary, acting through the review committee, shall conduct hearings to evaluate and review the existing standards and operating rules established under this section. Not later than July 1, 2018, and not less than biennially thereafter, the review committee shall provide recommendations for updating and improving such standards and rules. The review committee shall recommend a single set of operating rules per transaction standard and maintain the goal of creating as much uniformity as possible in the implementation of the electronic standards. Any recommendations to amend existing standards and operating rules that have been approved by the review committee and reported to the Secretary under paragraph (2)(B) shall be adopted by the Secretary through promulgation of an interim final rule not later than 90 days after receipt of the committee's report. The Secretary shall accept public comments on any interim final rule published under this paragraph for 60 days after the date of such publication. The effective date of any amendment to existing standards or operating rules that is adopted through an interim final rule published under this paragraph shall be 25 months following the close of such public comment period. For the purposes of this subsection, the term review committee means a committee within the Department of Health and Human services that has been designated by the Secretary to carry out this subsection, including— the National Committee on Vital and Health Statistics; or any appropriate committee as determined by the Secretary. In developing recommendations under this subsection, the review committee shall consider the standards approved by the Office of the National Coordinator for Health Information Technology. Not later than April 1, 2018, and annually thereafter, the Secretary shall assess a penalty fee (as determined under subparagraph (B)) against a health plan that has failed to meet the requirements under subsection
(h)with respect to certification and documentation of compliance with the standards (and their operating rules) as described under paragraph
(1)of such subsection. Subject to subparagraphs (C), (D), and (E), the Secretary shall assess a penalty fee against a health plan in the amount of $1 per covered life until certification is complete. The penalty shall be assessed per person covered by the plan for which its data systems for major medical policies are not in compliance and shall be imposed against the health plan for each day that the plan is not in compliance with the requirements under subsection (h). A health plan that knowingly provides inaccurate or incomplete information in a statement of certification or documentation of compliance under subsection
(h)shall be subject to a penalty fee that is double the amount that would otherwise be imposed under this subsection. The amount of the penalty fee imposed under this subsection shall be increased on an annual basis by the annual percentage increase in total national health care expenditures, as determined by the Secretary. A penalty fee assessed against a health plan under this subsection shall not exceed, on an annual basis— an amount equal to $20 per covered life under such plan; or an amount equal to $40 per covered life under the plan if such plan has knowingly provided inaccurate or incomplete information (as described under subparagraph (C)). The Secretary shall determine the number of covered lives under a health plan based upon the most recent statements and filings that have been submitted by such plan to the Securities and Exchange Commission. The Secretary shall establish a procedure for assessment of penalty fees under this subsection that provides a health plan with reasonable notice and a dispute resolution procedure prior to provision of a notice of assessment by the Secretary of the Treasury (as described under paragraph (4)(B)). Not later than May 1, 2018, and annually thereafter, the Secretary shall provide the Secretary of the Treasury with a report identifying those health plans that have been assessed a penalty fee under this subsection. The Secretary of the Treasury, acting through the Financial Management Service, shall administer the collection of penalty fees from health plans that have been identified by the Secretary in the penalty fee report provided under paragraph (3). Not later than August 1, 2018, and annually thereafter, the Secretary of the Treasury shall provide notice to each health plan that has been assessed a penalty fee by the Secretary under this subsection. Such notice shall include the amount of the penalty fee assessed by the Secretary and the due date for payment of such fee to the Secretary of the Treasury (as described in subparagraph (C)). Payment by a health plan for a penalty fee assessed under this subsection shall be made to the Secretary of the Treasury not later than November 1, 2018, and annually thereafter. Any amount of a penalty fee assessed against a health plan under this subsection for which payment has not been made by the due date provided under subparagraph
(C)shall be— increased by the interest accrued on such amount, as determined pursuant to the underpayment rate established under section 6601 of the Internal Revenue Code of 1986; and treated as a past-due, legally enforceable debt owed to a Federal agency for purposes of section 6402(d) of the Internal Revenue Code of 1986. Any fee charged or allocated for collection activities conducted by the Financial Management Service will be passed on to a health plan on a pro-rata basis and added to any penalty fee collected from the plan. . The Secretary shall promulgate a final rule to establish a unique health plan identifier (as described in section 1173(b) of the Social Security Act ( 42 U.S.C. 1320d–2(b) )) based on the input of the National Committee of Vital and Health Statistics. The Secretary may do so on an interim final basis and such rule shall be effective not later than October 1, 2016. The Secretary shall promulgate a final rule to establish a standard for electronic funds transfers (as described in section 1173(a)(2)(J) of the Social Security Act, as added by subsection (a)(2)(A)). The Secretary may do so on an interim final basis and shall adopt such standard not later than January 1, 2016, in a manner ensuring that such standard is effective not later than January 1, 2018. Section 1862(a) of the Social Security Act ( 42 U.S.C. 1395y(a) ) is amended— in paragraph (23), by striking the or at the end; in paragraph (24), by striking the period and inserting ; or ; and by inserting after paragraph
(24)the following new paragraph: not later than January 1, 2018, for which the payment is other than by electronic funds transfer
(EFT)or an electronic remittance in a form as specified in ASC X12 835 Health Care Payment and Remittance Advice or subsequent standard. . Not later than July 1, 2017, the Secretary of Health and Human Services shall submit a report to the chairs and ranking members of the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives and the chairs and ranking members of the Committee on Health, Education, Labor, and Pensions and the Committee on Finance of the Senate on the extent to which the Medicare program and providers that serve beneficiaries under that program, and State Medicaid programs and providers that serve beneficiaries under those programs, transact electronically in accordance with transaction standards issued under the Health Insurance Portability and Accountability Act of 1996, part C of title XI of the Social Security Act, and regulations promulgated under such Acts.
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- 42 USC 1320d–2
- 42 USC 1320d–2(b)
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Sec. 613
Administrative simplification
Cite42 USC 1320d–2
Cite42 USC 1320d–2(b)
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