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Compliance, Certification, and Penalties

On January 2, 2014 the Department of Health and Human Services (HHS) issued a proposed rule under section 1104 of the Affordable Care Act related to the health plan compliance, titled: "Administrative Simplification: Health Plan Certification of Compliance.”   Comments were due in March, and HHS provided an extension to the comment period through April.  The comment period is now closed, and HHS is currently analyzing the comments it received.   Under section 1104, health plans are required to "certify" their compliance with the mandates of HIPAA and the Affordable Care Act, specifically,  with certain adopted standards and operating rules.

The proposed HHS rule defines controlling (CHPs) and sub health plans, and proposes that controlling health plans (CHPs) must submit documentation that demonstrates compliance with the adopted standards and operating rules for three electronic transactions:

1. Eligibility for a health plan
2. Health care claim status
3. Health care electronic funds transfers (EFT) and remittance advice

The rule proposes that controlling health plans submit their certification on or before December 31, 2015.  This proposed rule would also establish penalty fees for a CHP that fails to comply with the certification of compliance requirements.  

For additional information on the Affordable Care Act and it's relationship to Administrative Simplification, please go to the “Related Links” section below or to the FAQs for the 1104 provisions.