Statutes and Regulations

CMS Timeline
View the 20-year history of key Administrative Simplification laws and regulations (PDF)

Key Compliance Dates for Adopted Standards

• March 24, 2020 – D.0 Modification to Identify Partial Fills for Schedule II Drugs in the Quantity Prescribed (460-ET) Field (PDF)
• Oct 1, 2015 – ICD-10
• Jan 1, 2014 – Electronic Funds Transfer (EFT)/Electronic Remittance Advice (ERA) Standards and Operating Rules
• Jan 1, 2013 – Eligibility and Claims Status Operating Rules
• Jan 1, 2012 – Version 5010, D.0 and 3.0

Statutes

The primary statutes with Administrative Simplification provisions are

• The Health Insurance Portability and Accountability Act of 1996 (HIPAA), enacted to improve the efficiency and effectiveness of the nation’s health care system, includes Administrative Simplification provisions to establish national standards for:
  • Electronic health care transactions and code sets
  • Unique identifiers

 

HIPAA also defines privacy and security requirements for protected health information.

• The Patient Protection and Affordable Care Act (ACA) expanded on the HIPAA provisions. The ACA requires operating rules for transactions, reiterates the standards for electronic funds transfer and claims attachments and the requirement for a unique health plan identifier (HPID) (HPID rescinded in 2019), and requires health plan certification of compliance (rescinded in 2017). In a separate provision, the ACA directs HHS to conduct outreach to advisory bodies, including the National Committee for Vital and Health Statistics (NCVHS), for input on potential improvements to Administrative Simplification such as:
  • Use of a uniform enrollment for health care providers
  • Expanding scope of standards and operating rules to apply to health-related transactions conducted by organizations like auto insurers
  • Standardized forms for financial audits required by health plans and others
  • More transparent and consistent approach to claims edits by health plans
• The Administrative Simplification Compliance Act (ASCA) requires all claims be submitted to Medicare electronically except in certain circumstances. To learn more:
  • ASCA Enforcement Reviews
  • ASCA Self Assessment
  • ASCA Waiver Application