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Attention Clearinghouses and Health Plans: More Openings to Participate in the HHS Optimization Project Pilot

HHS is now offering more clearinghouses and health plans a chance to participate in a pilot program to check for compliance with adopted standards, code sets, unique identifiers, and operating rules.

Launched earlier this year, the Administrative Simplification Optimization Program pilot gives volunteers a chance to submit electronic transaction files for review and testing by HHS. Volunteers also attest to compliance with operating rules.

Volunteers selected to participate will receive a compliance review package with details about the process.

Upon completion, HHS will provide volunteers with a report that flags any issues that need to be addressed for full compliance. During the pilot, HHS will identify compliance issues and areas for optimization, and volunteers will develop a corrective action plan to remedy areas of noncompliance.

Volunteers that achieve successful reviews will receive a dated certificate of participation. Volunteers may choose to share their certificate with potential business associates, the public, and other stakeholders.

This pilot will inform the rollout of the Administrative Simplification Optimization Program, where HHS will begin conducting proactive compliance reviews of randomly selected health plans and clearinghouses.  

Volunteers for the pilot can send an email now to the mailbox. Any HIPAA-covered health plan or clearinghouse may volunteer.

HHS will choose participants on a first-come, first-served basis from emails received by April 20, 2018.

Sign up now to volunteer for our optimization project pilot. Write to today!

What You Need to Know about HHS Optimization Project Pilot

Providers and health plans use a variety of different formats for conducting electronic transactions. HIPAA Administrative Simplification transaction standards work towards reducing the variable formats, making it easier for data to be shared and transferred.

The 2016 CAQH Index estimates that industry-wide compliance with the adopted standards could save providers nearly $8 billion annually, with overall savings to the industry projected at more than $9 billion. The report analyzed the financial impact for the following transactions:

  • Claim submission/receipt
  • Eligibility and benefits verification
  • Prior authorization
  • Claim status inquiry
  • Claim payment (electronic funds transfer)
  • Claim remittance advice
  • Claim attachments (standards not yet adopted)

Achieving the full benefits of Administrative Simplification requires industry-wide compliance. To that end, HHS will pursue proactive compliance reviews of health plans and clearinghouses for compliance with Administrative Simplification transaction standards. We intend that our compliance reviews for compliant use of the HIPAA Administrative Simplification transaction standards will result in an environment that requires minimal government intervention because entities are conducting electronic transactions in adopted standard formats.

Why Compliance Reviews?

Health care providers, health plans, and clearinghouses have encouraged CMS to take proactive steps, including reviews, to ensure compliance with Administrative Simplification transaction standards, which will:

  • Reduce the burden on compliant entities of needing to exchange health care information with trading partners that are not compliant with the adopted standards
  • Improve efficiency across the health care system by streamlining communications about billing and insurance related matters, which allows providers and health plans to spend less time on these tasks

Our proactive approach implements a progressive penalty process with the goal of remediation, not punishment. However, the full array of enforcement actions are also possible, which includes corrective action plans (CAPs) and HHS technical assistance. 

New video:  Reaching Compliance with ASETT

To help the health care community use electronic standards for administrative transactions, CMS announces a new video, Reaching Compliance with ASETT.

This animated short: 

  • Explains the benefits of complying with Administrative Simplification standards, including substantial cost savings
  • Describes how ASETT—the Administrative Simplification Enforcement and Testing Tool—allows you to test transactions, both your own and your business trading partners’ transactions
  • Tells you how to use ASETT to file a complaint if you have any noncompliant business trading partners

Interoperability Standards Advisory Addresses Administrative Simplification

New in 2017, ONC's annual Interoperability Standards Advisory (ISA) includes administrative standards and operating rules in the 2018 ISA Reference Edition.  The ISA is designed to provide clarity, consistency, and predictability around standards and implementation specifications that could be used for a given interoperability purpose.  With the addition of the administrative standards, providers have even greater opportunities for their administrative and clinical systems to connect.   

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