Operating rules enforcement date delayed 90 days to avoid 'significant disruption'


In December 2011, the Department of Health & Human Services (HHS) finalized a rule requiring health plans, clearinghouses and providers to comply with operating rules for two electronic healthcare transactions. HHS said compliance with the rule would make it easier – through greater uniformity of information and transmission formats -- for providers to determine whether a patient is eligible for health insurance coverage, and to determine the status of a healthcare claim submitted to a health insurer.

HHS set a compliance date of Jan. 1, 2013 for the operating rules.

On Jan. 2, 2013, the Centers for Medicare & Medicaid Services' Office of E-Health Standards and Services (OESS) announced that it will not initiate enforcement action until March 31, 2013, with respect to HIPAA covered entities (including health plans, health care providers, and clearinghouses, as applicable) that are not in compliance with the operating rules.  OESS said it delayed the enforcement date "to reduce the potential of significant disruption to the healthcare industry." 

OESS said "industry feedback suggests that HIPAA covered entities have not reached a threshold whereby a majority of covered entities would be able to be in compliance with the operating rules by Jan. 1, 2013. This enforcement discretion period does not prevent applicable HIPAA covered entities that are prepared to conduct transactions using the adopted operating rules from doing so, and all applicable covered entities are encouraged to determine their readiness to use the operating rules as of Jan. 1, 2013 and expeditiously become compliant."

OESS is the HHS component that enforces compliance with HIPAA transaction and code set standards, including operating rules, identifiers and other standards required under HIPAA by the Affordable Care Act.

Notwithstanding OESS’ discretionary application of its enforcement authority, the compliance date for using the operating rules remains Jan. 1, 2013. Although enforcement action will not be taken, OESS will accept complaints associated with compliance with the operating rules beginning Jan. 1, 2013. If requested by OESS, covered entities that are the subject of complaints (known as “filed-against entities”) must produce evidence of either compliance or a good-faith effort to become compliant with the operating rules during the 90-day period.

HHS said it will continue to work to align the requirements under Section 1104 of the Affordable Care Act to optimize industry’s ability to achieve timely compliance.

Click here for more information on the operating rules for patient eligibility and claim status.