8. Standard: Referral Certification and Authorization (Subpart R)

a. Background

Increasingly, the delivery of health care is focused on achieving greater value from each health care dollar, and rigorous monitoring of health care utilization has become a common method adopted by health plans for achieving their value goals. Traditional methods of communication between health care providers and health plans or their designates, which rely on a combination of paper forms and telephone calls, are neither efficient nor cost effective and may impede the delivery of care. The burden and inefficiencies of these communications could be reduced by the adoption of standardized and electronic methods for making the requests and receiving responses.

i. Candidates for Standard.

According to the inventory of standards produced by the HISB for HHS, there is only one standard available for referral certification and authority. It is the ASC X12N 278, Health Care Services Review Information.

ii. Recommended Standard.

The ANSI ASC X12N 278 - Health Care Services Review Information is the standard proposed for electronic exchange of requests and responses between health care providers and review organizations.

These exchanges of information can be initiated by either the health care provider or the health plan. The health care provider requests from a designated review entity authorization or certification for a patient to receive a particular health care service. In turn, the review entity receives and responds to the health care provider’s request. In addition to direct electronic inquiry and response, the ASC X12N 278 can be used in connection with point of service terminals.

Many different types of organizations may act as a review entity in such an exchange. These include health plans, insurance companies, health maintenance organizations, preferred provider organizations, health care purchasers, managed care organizations providing coverage to Medicare and Medicaid beneficiaries, professional review organizations, other health care providers, and benefit management organizations, to name a few.

These requests and responses may pertain to many different health care events, including reviews for: treatment authorization, specialty referrals, pre-admission certifications, certifications for health care services (such as home health and ambulance), extension of certifications, and certification appeals.

As with all the other ASC X12 transactions being proposed in this rule, the ASC X12N 278 was developed with widespread input from health care industry representatives in a consensus process taking into account business needs. Further, the standard is fully compatible with the other ASC X12 standards and can be translated to and from native application systems using off-the- shelf software (commonly referred to as “translators”) that is readily available and used by all industries utilizing ASC X12 standards.

The data elements for this transaction, and other information, may be found in Addendum 8.

b. Requirements

In § 142.1802, we would specify the following as the standard for referral certifications and authorizations: ASC X12N 278 - Request for Review and Response (004010X094). We would specify where to find the implementation guide and incorporate it by reference.

i. Health plans.

In § 142.1804, Requirements: Health plans, we would require health plans to accept and transmit only the standard specified in § 142.1802 for electronic referral certifications and authorizations.

ii. Health care clearinghouses.

We would require in § 142.1806 that each health care clearinghouse use the standard specified in § 142.1802 for referral certifications and authorizations.

iii. Health care providers.

In § 142.1808, Requirements: Health care providers, we would require each health care provider that transmits referral certifications and authorizations electronically to use the standard specified in § 142.1802 for the transactions.

c. Implementation Guide and Source

The implementation guide for the ASC X12N 278 (004010X094) is available at no cost from the Washington Publishing Company site on the World Wide Web at the following address: http://www.wpc-edi.com/hipaa/.

Users without access to the Internet may purchase implementation guides from Washington Publishing Company directly. Washington Publishing Company, 806 W. Diamond Ave., Suite 400, Gaithersburg, MD, 20878; telephone 301-590-9337; FAX: 301-869- 9460.

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