Checking Eligibility - About to Get Easier

July 3, 2011

On June 30, 2011, the Department of Health and Human Services (HHS) released an interim final rule which began to implement long-awaited Administrative Simplification provisions originally mandated under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.  The new operating rules governing electronic claims status and health plan eligibility inquiries are estimated to save $12 billion over the next decade.   


These new electronic standards will allow physicians that routinely track down eligibility or claims status inquiries to spend less time (and money) on these tasks.   The interim final rule (IR) requires compliance by health plans, health care clearinghouses, and certain health care providers by January 1, 2013.  The IR puts in place rules that will make it easier for providers to determine patient eligibility and the status of a health care claim submitted to a health insurer.  Currently, physician staff must use multiple systems for information requests for different insurers; if adopted, the new rules will allow providers to use one uniform system that provides the level of detailed information the office needs.   Failure to comply with the new standards could result in severe fines being imposed on health plans found to be out of compliance. 


The standards CMS is proposing to adopt were originally developed by the Council for Affordable and Quality Healthcare’s Committee on Operating Rules for Information Exchange (CAQH CORE).  CMS intends to release additional standards and operating rules for electronic funds transfers, a standard unique identifier for health plans, a standard for claims attachments and requirements that health plans comply with HIPAA rules in the not too distant future.


One of our strengths at MedFocus is helping clients stay current and compliant with the many changes in medical coding, medical billing and revenue cycle management today.

Contact us to find out more about how we can help you run your practice more easily and maximize your financial success.

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