Fact Sheets

Administrative Simplification: Certification of Compliance for Health Plans (CMS-0037-P)

Administrative Simplification: Certification of Compliance for Health Plans (CMS-0037-P)

The Department of Health and Human Services (HHS) today announced a proposed rule, entitled “Administrative Simplification: Certification of Compliance for Health Plans.” This rule proposes that controlling health plans (CHPs) must submit certain information and documentation that demonstrates compliance with the adopted standards and operating rules for three electronic transactions: eligibility for a health plan, health care claim status, and health care electronic funds transfers (EFT) and remittance advice. This proposed rule would also establish penalty fees for a CHP that fails to comply with the certification of compliance requirements.

The documentation of compliance requirements proposed in this rule would demonstrate that CHPs have done some external testing of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Administrative Simplification requirements with trading partners.

In this rule, we propose to require CHPs to obtain and submit to HHS one of two documents from the Council for Affordable Quality Healthcare’s Committee on Operating Rules for Information Exchange (CAQH CORE):

     1. A Certification Seal for Phase III CAQH CORE Operating Rules. In order to be awarded a Certification Seal for Phase III CAQH CORE Operating Rules, a CHP must submit specific documentation to a testing vendor (not CAQH CORE) that demonstrates compliance with each of the CAQH CORE operating rules (among other requirements); or

     2. A HIPAA Credential. In order to receive a HIPAA Credential, a CHP must sign an attestation that states that, for each of the three transactions, the CHP has successfully tested with at least three trading partners that collectively conduct at least 30 percent of the CHP’s transactions with providers (among other requirements).

The rule proposes that CHPs may choose between the two CAQH CORE documents, as opposed to submitting documentation from other certifying or administrative entities, because CAQH CORE:

     • Is recognized as a technical expert in the implementation of operating rules. CAQH CORE is the authoring entity of the adopted operating rules and is, therefore, well versed in the operating rules and their interpretation and implementation, and how they coordinate with the adopted standards;

     • Has infrastructure to reach out to, and educate, CHPs about the Certification Seal for Phase III CAQH CORE Operating Rules and HIPAA Credential; and

     • Has the ability to convene workgroups with significant and diverse health care industry participation to continually inform, and, where appropriate, improve processes associated with the Certification Seal for Phase III CAQH CORE Operating Rules and HIPAA Credential products.

     • CORE Certification is a recognized Administrative Simplification tool for health plans and States.

CHPs would be required to submit information and documentation of compliance by December 31, 2015. CHPs, as defined in the Health Plan Identifier (HPID) Final Rule, would also be responsible for submitting the required information and documentation on behalf of their subhealth plans.

This proposed rule would also establish penalty fees for CHPs that do not comply with the certification of compliance requirements. A penalty fee would be assessed if a CHP fails to comply with the requirements by the date required.

Administrative Simplification Compliance Dates

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