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- WELCOME TO CMS EHEALTH!
AS A PROVIDER, YOU KNOW THAT TOO MUCH TIME SPENT
ON PAPERWORK...
CAN MEAN LESS TIME FOR PATIENTS.
EVERY YEAR, THE UNITED STATES SPENDS BILLIONS OF DOLLARS
ON HEALTH CARE ADMINISTRATION ALONE!
OUR GOAL IS TO REDUCE THAT COST BY MAKING THE
ADMINISTRATIVE SIDE OF HEALTH CARE MORE EFFICIENT...
FOR EXAMPLE, WE WANT TO MAKE IT EASIER FOR PROVIDERS
AND HEALTH PLANS TO SHARE ADMINISTRATIVE
INFORMATION ELECTRONICALLY.
AND THAT'S THE GOAL OF ADMINISTRATIVE SIMPLIFICATION.
LET'S START WITH THE WHAT, HOW AND WHY OF OPERATING RULES
AND STANDARDS.
WHAT DO OPERATING RULES DO?
THEY SET CERTAIN REQUIREMENTS FOR TRANSACTIONS BETWEEN
ENTITIES THAT ARE COVERED BY THE HEALTH INSURANCE
PORTABILITY AND ACCOUNTABILITY ACT OF 1996, OR HIPAA.
HOW DO THEY WORK?
THEY SPECIFY THE INFORMATION THAT MUST BE INCLUDED WHEN
CONDUCTING STANDARD TRANSACTIONS.
AND HERE'S THE "WHY": OPERATING RULES MAKE IT EASIER
FOR PROVIDERS TO USE ELECTRONIC MEANS TO MAKE
ADMINISTRATIVE TRANSACTIONS.
WE'LL LOOK AT FOUR DIFFERENT KINDS OF ADMINISTRATIVE
TRANSACTIONS, AND THEIR ASSOCIATED OPERATING RULES
AND STANDARDS.
THE FIRST TWO TRANSACTIONS DEAL WITH ELIGIBILITY FOR A HEALTH
PLAN AND WITH CLAIM STATUS.
THE OPERATING RULES FOR THESE TRANSACTIONS HAVE BEEN
IN EFFECT SINCE JANUARY 1, 2013.
WHAT THIS MEANS TO YOU, THE PROVIDER, IS THAT YOU SHOULD BE
ABLE TO CHECK ON A PATIENT'S ELIGIBILITY, OR THE STATUS
OF A CLAIM, OVER THE INTERNET.
BUT THIS RULE IS ABOUT MORE THAN JUST CONVENIENCE.
IT INCREASES EFFICIENCY BY REDUCING BACK-AND-FORTH
COMMUNICATION AND THE EXTRA TIME SPENT CHASING
DOWN INFORMATION.
THAT'S BECAUSE UNDER THIS RULE, HEALTH PLANS ARE
REQUIRED TO RESPOND TO YOUR ELIGIBILITY QUESTIONS
WITH DETAILS ABOUT A PATIENT'S COVERAGE...LIKE
THE DEDUCTIBLE AND ALLOWABLE CHARGES FOR SPECIFIC SERVICES.
THIS STANDARD ALSO MAKES BOTH THE INFORMATION AND THE WAY
IT'S TRANSMITTED MORE UNIFORM, SO THAT PROVIDERS CAN USE JUST
ONE TYPE OF ELECTRONIC REQUEST FOR ALL INSURERS, INSTEAD
OF USING MANY DIFFERENT SYSTEMS.
OUR THIRD TRANSACTION IS THE HEALTH CARE ELECTRONIC FUNDS
TRANSFERS, OR EFT, AND REMITTANCE ADVICE.
THAT'S THE ELECTRONIC PAYMENT THAT A HEALTH PLAN SENDS TO
THE BANK TO PAY PROVIDER CLAIMS.
ACCOMPANYING EVERY EFT IS AN ERA, OR ELECTRONIC
REMITTANCE ADVICE.
AN ERA IS WHAT HEALTH PLANS SEND TO PROVIDERS TO DESCRIBE
WHAT A HEALTH CARE PAYMENT IS FOR.
YOU MIGHT THINK OF IT AS A TRANSACTION PROCESSING SUMMARY.
SO, HOW DO THE ADMINISTRATIVE SIMPLIFICATION OPERATING RULES
AND STANDARDS AFFECT EFT AND ERA?
THEY SPECIFY BOTH THE FORMAT AND THE DATA CONTENT
OF EACH TRANSACTION.
THIS WILL SIMPLIFY THE PROCESS OF SIGNING UP FOR EFT
AND AUTOMATE PAYMENT RECONCILIATION FOR PROVIDERS.
TO FIND OUT MORE GO TO THE EHEALTH WEBSITE AND LOOK
FOR ADMINISTRATIVE SIMPLIFICATION
UNDER THE PROGRAMS TAB.