II. Provisions of the Proposed Regulations

The Secretary reviewed the changes recommended by the NCVHS and is proposing their adoption in this rule.

A. Summary

This rule proposes to make some limited technical modifications to some of the transactions standards, specifically the implementation specifications, adopted in the Transactions Rule by adopting those changes identified by the DSMOs, and approved by the NCVHS, as necessary to permit initial implementation of the standards within the industry. Details of the proposed modifications are not set forth specifically in this document, but are available at: http://hipaa-dsmo.org/crs/fasttrack.pdf. A summary of those details follows:

A total of 231 change requests were submitted to the DSMOs for consideration. 85 requests were rejected because the implementation specifications already met the specified business need, or the business need was not well substantiated. 21 requests were recommended for future changes. 6 requests were withdrawn by the submitter. 7 requests were referred to the Department as policy issues. The remaining 115 change requests were approved and are included in the draft addenda. They fell into 2 categories--48 maintenance changes (minor error corrections, clarifications) and 67 modifications to the standards.

Details of these 67 modifications include:

Changing required data elements to situational (about 20 % of changes) Submitters pointed out several data elements that were required by the original standards, but were really only needed in some situations. These data elements were made situational in the addenda, with clearly defined situations. Examples are:

1. Provider Taxonomy codes on claims-many health plans store this information on their systems when providers enroll, so there is no need to continually send this information. The code will now only be reported "when adjudication is known to be impacted by the code."
   
   
2. Date last seen by physician (used for certain physical therapy claims)--this is only needed by Medicare, so usage was changed from required on all claims to "required on Medicare claims."

Removal of certain data elements (about 20% of changes)

Several data elements were removed since they do not appear to be needed.

Examples are:

1. Referral date
2. Estimated date of birth

Allowing certain items to be reported via external code sets rather than data elements in the transaction (about 20% of changes)

There were several instances where codes could be used to indicate certain data elements. This will allow external code set organizations to easily update codes and reporting, as opposed to having the DSMOs make changes to the standards.

Examples are:

1. Special program indicator codes
2. Newborn birth weights

Adding additional functionality to some transactions (about 40% of changes) Requestors suggested several additional data elements, codes, or loops to enable them to do certain business functions in the transactions. These include:

1. Cross-referencing two subscriber IDs (surviving spouse and dependents)
2. Sending a patient's primary care physician number

The DSMOs and the NCVHS determined that these proposed modifications would respond to industry requests for changes that would facilitate HIPAA implementation.

The SSOs have incorporated the proposed modifications for each transaction into draft addenda for each implementation specification. These draft addenda represent the final product of the DSMO change request process, in that the requested change successfully completed the DSMO change request process in the form of proposed draft addenda to the adopted implementation specifications. As previously discussed, the original implementation specifications are incorporated by reference. This rule proposes to adopt the modifications in the draft addenda. The addenda would be incorporated by reference just as are the original implementation specifications. We are are soliciting comments specifically on those modifications found in the draft addenda. Comments may be submitted for specific individual proposed modifications or for the proposed modifications collectively. The full text of the draft addenda can be obtained from the

telephone 301-949-9740

They are also available through the Washington Publishing Company on the Internet at http://hipaa.wpc-edi.com/HIPAAAddenda_40.asp.

B. Proposed Modifications

The Transactions Rule established standards for eight electronic transactions, including, when appropriate, specific standards tailored to specific industry sectors, for example, retail pharmacy, institutional, and professional. The modifications proposed here would affect some of the transaction standards (identified below). The new standards would consist of the implementation guide plus the addenda. The addenda are identified below:

1. Health care claims or equivalent encounter information (Sec. 162.1102).

a. Dental Health Care Claims. The ASC X12N Addenda to Health Care Claim: Dental, Version 4010, May 2000, Washington Publishing Company,
004010X097A1 (NPRM Draft Addenda October 2001).

b. Professional Health Care Claims. The ASC X12N Addenda to Health Care Claim: Professional, Volumes 1 and 2, Version 4010, May 2000,
Washington Publishing Company, 004010X098A1 (NPRM Draft Addenda October 2001).

c. Institutional Health Care Claims. The ASC X12N Addenda to Health Care Claim: Institutional, Volumes 1 and 2, Version 4010, May 2000, Washington Publishing Company, 004010X096A1 (NPRM Draft Addenda October 2001).

2. Eligibility for a health plan (Sec. 162.1202).

Dental, professional, and institutional. The ASC X12N Addenda to Health Care Eligibility Benefit Inquiry and Response, Version 4010, May 2000, Washington Publishing Company, 004010X092A1 (NPRM Draft Addenda October 2001).

3. Referral certification and authorization (Sec. 162.1302).

The ASC X12N Addenda to Health Care Services Review-Request for Review and Response, Version 4010, May 2000, Washington Publishing Company, 004010X094A1 (NPRM Draft Addenda October 2001). In the proposed rule titled CMS-0003-P, published elsewhere in this Federal Register issue, we are proposing to add a new paragraph (a) to this section.

4. Health care claim status (Sec. 162.1402).

The ASC X12N Addenda to Health Care Claim Status Request and Response, Version 4010, May 2000, Washington Publishing Company 004010X093A1 (NPRM Draft Addenda October 2001).

5. Enrollment and disenrollment in a health plan (Sec. 162.1502).

The ASC X12N Addenda to Benefit Enrollment and Maintenance, Version 4010, May 2000, Washington Publishing Company 004010X095A1 (NPRM Draft
Addenda October 2001).

6. Health care payment and remittance advice (Sec. 162.1602).

a. Dental, professional, and institutional health care claims and remittance advice. The ASC X12N Addenda to Health Care Claim Payment/Advice, Version 4010, May 2000, Washington Publishing Company, 004010X091A1 (NPRM Draft Addenda October 2001).

C. Compliance Dates

The compliance date for the standards for the transactions adopted in the Transactions Rule is October 16, 2002 for covered entities, with the exception of small health plans, for which the compliance date is October 16, 2003 (65 FR 50368). Under Sec. 160.104, the Secretary establishes the compliance date for modifications. The date must not be earlier than 180 days after the adoption date of the modification.

The Administrative Simplification Compliance Act (Pub. L. 107-105) was enacted on December 27, 2001. This law provides an extension to the compliance dates adopted in the Standards for Electronic Transactions final rule of August 17, 2000 (65 FR 50368), for covered entities, with the exception of small health plans, that submit a plan to the Secretary of Health and Human Services indicating how the entity will come into compliance by October 16, 2003. This plan must be submitted to the Secretary before October 16, 2002. Entities that obtain such an extension will also have a corresponding extension of the compliance dates set forth in this proposed rule.

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