The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires group health plans (and their business associates) that exchange information electronically in certain "covered transactions" to use standardized formats and uniform codes to conduct such transactions. The Patient Protection and Affordable Care Act (PPACA) directed the Secretary of Health and Human Services to "adopt a single set of operating rules for each transaction?."

HIPAA's administrative simplification rules were designed to standardize the format and content of electronic transactions, but the amount of flexibility in the rules resulted in covered entities implementing the standards in their own way. For example, in response to a physician's office electronic inquiry to a health plan about a patient's eligibility, one health plan may have responded simply "yes or no", requiring the physician's office to submit another inquiry if they needed information regarding co-pays and deductibles, while another health plan may have provided that level of information initially.

The Regulations

On July 8, 2011, the Department of Health and Human Services released Interim Final Regulations (the "Regulations") adopting operating rules for determining: 1) whether an individual is eligible for coverage under a group health plan, and 2) the status of a health plan claim, all within standardized response times. The Regulations require plans to comply with the rules by January 1, 2013. In response to an inquiry on eligibility, the Regulations specifically require a health plan to respond with information on a patient's eligibility and financial responsibility for a specified list of service codes including, dental, vision, medical, hospital inpatient and emergency care. The Regulations mandate uniform methods and standardize response times for communicating and exchanging patient information.


Plan sponsors should review business associate contracts and insurance contracts to ensure compliance with these new requirements.