[This transcript is unedited]
Department of Health and Human Services
National Committee on Vital and Health Statistics
Subcommittee on Standards
September 22, 2011
Embassy Row Hotel
2015 Massachusetts Avenue, Northwest
CASET Associates, Ltd.
Fairfax, Virginia 22030
TABLE OF CONTENTS
P R O C E E D I N G S (8:30 a.m.)
DR. WARREN: Our agenda is in the larger agenda book. The first thing we need
to do is go around and introduce ourselves and say whether or not you have any
I am Judy Warren from the University of Kansas School of Nursing, co-chair
of the subcommittee, and I have no conflicts.
MS. GREENBERG: Good morning. I am Marjorie Greenberg from NCHS, CDC, and
Executive Secretary to the Committee.
DR. CARR: Justine Carr, Steward Health Care, Chair of the Committee, member
of the subcommittee, no conflicts.
DR. CHANDERRAJ: Raj Chanderraj, practicing cardiologist, member of the
subcommittee, no conflicts.
MR. SOONTHORNSIMA: I am Ob Soonthornsima, Blue Cross and Blue Shield of
Louisiana, no conflicts.
DR. SUAREZ: I am Walter Suarez with Kaiser Permanente, member of the
subcommittee, no conflicts.
DR. SORACE: I am Jim Sorace, staff to the subcommittee, from ASPE, and no
MS. DOO: Lorraine Doo with the Office of E-Health Standards and Services,
lead staff to the subcommittee, and no conflicts.
(Introductions from around room)
MR. BIZARRO: Tom Bizarro, First DataBank.
MS. GILBERTSON: Lynne Gilbertson, National Council for Prescription Drug
MS. WEIKER: Margaret Weiker, HP.
MS. THORNTON: Jeanette Thornton, America’s Health Insurance Plans.
MS. HOLLAND: Priscilla Holland, NACHA.
MS. JONES: Katherine Jones, CDC, National Center for Health Statistics.
MS. FRIEDMAN: Maria Friedman, Brookside Consulting Group.
MR. BARDO: Lee Bardo, PricewaterhouseCooper.
MS. LOHSE: Gwen Lohse, CAQH CORE.
MS. WILSON: Nicole Wilson, Veterans Affairs.
MR. ALBRIGHT: Matthew Albright, Centers for Medicare & Medicaid Services
— no, Office of E-Health Standards and Services, sorry.
DR. WARREN: I’d like to just go over the agenda, and then we’re going to
turn it over to Walter. So, the first thing we’re going to do is spend just a
couple of minutes looking at our workplan for the coming year. And then, we’re
going to be talking about our review and action of the proposed operating rules
for EMT and ERA.
And from then, we’re going to go on and discuss our hearings that we’re
going to be having in November. And then, hopefully, we will save just a few
minutes for any public comment. So Walter, you’ve got the —
DR. SUAREZ: Yes, thank you. So, the first thing we wanted to do very briefly
is to go over the workplan of the subcommittee. And what we wanted to do was
first go over a couple of slides. These are not in your packet. They were put
together as part of a discussion that the Executive Subcommittee is having on
the work of the Full Committee.
So, this is our subcommittee themes and stakeholders and some of the ideas,
a couple of slides so just very quickly to go over those. So we yesterday
discussed, there is a sort of a series of requirements that we have as a
Committee and then all responsibility of the subcommittee related to the HIPAA
Administrative Simplification Regulations and Standards.
So, this slide summarizes basically all those primarily under the HIPAA
Administrative Simplification, we’re looking at the current and future
transaction standards, 5010/D.0 and the next versions. We’re looking at the
current and future code set standards, ICD-10, HCPCS and other code sets and
the identifiers as well. So, that’s sort of part of the bigger actions of
We’re not directly responsible for the other components of HIPAA, the
privacy and security regulations. But as part of the discussions that we have,
we always include the privacy and security aspects of HIPAA.
The Affordable Care Act added a number of areas, and they’re briefly
summarized here, related to transactions and code sets and standards. So, one
of them was a designation of a standard for EFT and the implementation
specifications. The other one is the larger component of the operating rules
for all the transactions, and that is sort of one of our responsibilities now
as well. Claim attachments standards is another one with the corresponding
implementation specs and operating rules.
And then section 10109 of the Affordable Care Act which identifies a series
of new areas for standardization. And, we’ll talk about those later. And the
new administration publication areas that were not covered either in the HIPAA
or the Affordable Care Act legislation include the acknowledgements of
standards and specs and operating rules. And then, this whole process of
improvement of the modification and maintenance of the standards and operating
So, those are all components of our responsibilities related to the
administrative simplification aspects and provisions of HIPAA and the
Affordable Care Act. And there probably are going to be some new areas in the
administration publication side that are not listed here, but we’re going to be
probably looking into as we move forward with things.
Then, there’s an expanded or future standards. And this is where we might
want to have just a brief notation of this. We are not going to have a full
discussion today but just to plant some seeds in your minds about new areas
that our Committee, beyond the sphere of HIPAA, would want to consider looking
One of them is public health data standards, the concept of bi-directional
exchange of information between public health, clinical care, all the other
entities that are involved in the healthcare industry and national and
international standard for public health messaging and reports. There is a push
nationally through initiatives like this and a framework for the standards and
interpret the framework of the Office of the National Coordinator, H07, ISO,
the Public Health Data Standards Consortium, JPHIT (the Joint Public Health
All these entities are moving towards harmonizing and coordinating better
the public health messaging that covers everything in the public health sphere,
not just messaging related to things like syndromic surveillance or
immunizations and everything else. So, this is an area that we, as the
Standards Subcommittee and the Standards Subcommittee of National Committee on
Vital Health Statistics would be interested in focusing on and looking into.
The second big area is the public health information architecture or
information technology architecture reference model and all these related
aspects of the concept of helping define a reference model for public health
agencies to look at their enterprise architecture, their information model
applicable to public health, health terminology model applicable to public
health. So, all these are areas that we would like to keep an eye on and
probably look into focusing into the next year in several months.
The standards for personal health records, that would be another area as
things continue to evolve in that sphere. The Committee, through the Privacy
and Security Subcommittee, looked into personal health records from a privacy
and security perspective. We might want to consider looking at it from a
messaging and content standards perspective. This is an area that really not a
lot of work has been done necessarily from an advisory committee perspective.
So, that’s one side.
Standards for APCDs, we’ve worked on that a little bit already. And, there
might be other areas, a location, an outreach around standards, new primers,
those kind of things. Our stakeholders, of course, are a whole host of members
of the industry, public health, federal, state, local, providers,
clearinghouses, researchers, policymakers, consumers. All of these are really
stakeholders of our subcommittee work.
So, these are just some ideas. And as a subcommittee and members of our
subcommittee and others could think of other areas that we should consider to
include in our larger sphere of activities beyond HIPAA, I think that would be
So, let me stop here and see if there are some brief comments about that
just to see what people think. Yes, Marjorie?
MS. GREENBERG: I’m just thinking maybe you need a few more things to do.
(Laughter) No, I would just, I perked up probably not surprisingly when you,
not that I was asleep, but when you mentioned public health data standards. And
we were talking yesterday when you were there in the population and privacy
group about the Population Health Subcommittee having a hearing possibly around
socioeconomic factors and social determinants of health.
And, I was just thinking it would be really good if you recall had the
bandwidth to partner with them on that because there’s, of course, the
collection of the data and surveys which is, right now I think, the principle
focus of the Department that was the focus of the original, of the standards
they recently put out on race, ethnicity, etcetera. But it’s, collecting these
things in surveys is one thing. Trying to get them in administrative data and
even in clinical data in a standardized way is much more challenging.
And I think having your perspective on that and your expertise would be a
good balance with the population health obviously, having the strong knowledge
about the value of the data and how it can be used. So I’d just, you know if
possible, if not, the whole subcommittee, well I mean you’re on both anyway.
But I think even in the planning of the hearing, it would be great to join with
them. Would you agree that that would be a good kind of balance?
DR. WARREN: The question I had, Marjorie, since I wasn’t here during the
discussion yesterday, is Quality involved in that as well? And the reason I’m
asking is that when we start looking at quality metrics, those also need to be
aligned with identification of the person, etcetera. So, it seems –-
MS. GREENBERG: Like risk adjustment or —
DR. WARREN: Yes. My own personal bias is if we don’t start aligning our
surveys, our PHRs, and our EHRs, and our administrative stuff on at least some
basic factors, –-
MS. GREENBERG: I agree.
DR. WARREN: — the we’re just going to stay in silos. And data will never
really be available to do everything that we need to do.
MS. GREENBERG: Well that’s what, yes, I mean then you can get more detail in
some settings. But, at least if you can get a basic standard, I mean that’s
music to my ears. It’s like so many things. I think we’ve discovered almost
everything is cross-cutting in this, you know, because there are privacy issues
DR. SUAREZ: This is precisely why, you know, one of the key elements of this
expanded area of focus for our subcommittee includes this concept of a health
information model for public health. Because in a health information model, and
I mentioned yesterday, that is one of the big things that large organizations
nowadays are looking into is developing an information model that covers all
the type of data that is captured, that is maintained, that is used, that is
exchanged by an entity and is harmonized in a way that even inside an
organization, you can actually use the data from different sources to do an
And then, you have to manipulate the data to convert this field because this
field was defined a little bit different for this particular data collection.
But, this other data collection had it a little bit different. And now to try
to use the data for the two is going to need some manipulation.
So, a lot of this conceptual development of a logical model for health
information, for public health is sort of the new frontier, if you will, the
new area for us to look into which includes, you know, what is the
administrative data that public health collects? What is the clinical data?
What is the environmental health data? All these aspects of public health.
And absolutely, I think this is one field where, one domain where we can
leverage the cross-subcommittee partnerships that we’ve been kind of building
nowadays. You know, public health or Population Health and Security and Privacy
are joining together while Standards and public health or Population Health
Subcommittees can work together on this as well.
MS. GREENBERG: I mean, you mentioned surveys, you know, it’s also vital
birth and death records. I mean, those are the bookends of a personal health
record. But, I’ve just seen so many years these different groups talking past
each other. But, I think there’s the opportunity here to hear that. So I’m
sorry, I didn’t mean to interrupt.
DR. WARREN: That’s okay.
MR. SOONTHORNSIMA: Considering on this page, all these listed items, if you
were to look at all the relevant work that other committees, as you were
talking about, are doing as well as work that other entities are working on,
for example, the standards of personal health records, I thought ONC is doing
some of that or CCHIT is doing some of that. I’m not sure.
DR. SUAREZ: Well no, I don’t think, this is an idea only just as a
placeholder more than anything. I don’t know that there’s any groups
specifically working on that only.
MR. SOONTHORNSIMA: Let me finish my point. What I’m saying is based on those
different aspects of relevant work that other committees are doing that we
could be working jointly, is there a priority or should we prioritize this list
in order for us to tangibly identify those areas that we could pull out that
have the biggest value?
DR. WARREN: Actually I agree, Ob. I think part of the prioritization is
doing some of our homework to see who is involved. If it’s industry, so the
public, no it’s the private that’s industry, never mind, anyway, the people who
are not the feds. How about that?
I think we need to find out who is involved because that’s something we can
pull them together in a series of hearings or workshops and bring that work
together and try to connect everybody. If other people within the government
are working on this, we need to contact them and see if they have, are
attacking it from the same perspective that we would and either collaborate
with them or say, you know, you’ve got it, and we’ll move on and tackle our
I think it was Lorraine. Have you talked to Lorraine?
DR. SUAREZ: Very quickly. I think the first step before even jumping into
prioritizing because I think clearly that is one goal, so the first step is to
complete this list. So are we looking at all the areas, or are we missing some
into the future aspects of what this subcommittee should be looking in?
So, the first step is to complete the list, see if anybody has other areas
beyond these ones that you think we should consider. And then, we have the
discussion about prioritizing and excluding something because some things might
be already covered by someone. I think, Lorraine?
MS. DOO: Just a quick comment for Ob, just CCHIT did start to work on a
certification for personal health records. But the standards were so unevolved
at the time, so they stopped that. And the HL-7 PHR System Functional Model
Workgroup is working on a standard for personal health records that connects to
the electronic health record model. So, there is work that’s going on there.
And then, of course, there is some of the work that ONC has been doing. But,
it’s not related to a PHR standard per se. And then of course, is the X12 PHR
to PHR transfer which is leveraging some of the HL7 CCD information.
So, there’s a lot of people that are doing great work. They are talking to
each other. But, there’s definitely a future opportunity for that of pulling
everyone together though.
DR. WARREN: I want to be mindful of time. So Seth, you’re the last
commenter. And after Seth, I have a couple of suggestions for how we continue
DR. FOLDY: Well what I was getting ready to say keeps changing. But I think
Walter asked a good first question, what might be missing? So what we’ve heard
is the concept of disparities and risk stratification variables,
race/ethnicity, occupation, class. That seems to be an area that isn’t on the
list. It sounds like it’s going to be a difficult one. It sounds like a very
fruitful one because it does have so many ramifications.
In terms of where CDC or at least where I see a lot of our priorities as
being placed, the unresolved issues of case reporting to public health from
clinical care and then the iterative communication that occurs afterwards seems
to be critical. It continues to actually be put at more and more risk as
emerging standards come down for which public health may or may not be
The business is changing under our feet, and we really need to resolve the
issue of how electronic reporting, not just electronic lab results, but of
cases of public health importance including clinical, non-lab information take
place. So, I think that’s on the list here as public health data standards. But
just to say that I see us as probably focusing at CDC and the larger enterprise
very heavily on case report notification and management and also laboratory
interoperability which, as people know, is very complex and involves many
different levels of public health labs.
The public health information technology architecture is something that is
generally being recognized as a crying need. There is also a kind of a crying
recognition that we don’t know how to get to something so big. And if this
Committee could figure out how to pay a role that is integrated with the role
of many other groups on this, it would be very valuable.
I think two things that I’m not sure I see on the list, although, they are
probably there somewhere, the issue of secure transport of information is
actually kind of unresolved. If you all remember, the public health developed
its PHINMS system ten years ago or so to move information securely from point
to point. And, it is pretty clearly outmoded in that we are not getting, it’s
And ONC is, if you will, dissing it a lot. And they have half-built
alternatives, though we don’t have a fully built alternative to handle
everything from identity management and authentication to security and
transport. That is, I think, what they mean, what people mean when they talk
about NW-HIN or Nationwide HIN, but we’re a little unclear as to how to make
sure public health stays in line with the emerging NW-HIN and to make sure that
emerging NW-HIN actually accommodates the needs of public health agencies. So,
I see transport as kind of being an urgent issue that doesn’t appear to be on
The last is we spent a huge amount of effort, we spent a lot of time on the
message formats and not much time on vocabulary of, semantic interoperability
at the vocabulary level. And, I think that’s an area where we’re anxious to get
to as soon as we get a few of these other big problems out of the way.
DR. WARREN: Okay. So we are way over time limit on this. My suggestion is
Walter and I will add your notes to these two slides. And then we’ll circulate
that out to the subcommittee, have you add in your comments or add another,
probably add another slide for your comments on there. And then, we will try to
work this up offline into an action plan.
And I’m sure we’ll be having some conference calls probably between now and
November, and we can further the discussion then, be sure that we’ve captured
it. And if while you’re thinking about your comments, especially for you Ob, if
you know of people that are already in the space that are doing work, if you
could add stakeholders to this list, it would help us generate a strategy for
prioritizing that work.
DR. SUAREZ: So just to finish up then, these are the two slides about the —
DR. WARREN: Yes, but I don’t think we have time for that. We’re just going
to circulate. We need to get on to the ERA/EFT because we’re already about 20
minutes over. We have 45 minutes before the Full Committee.
DR. SUAREZ: We are going to talk next about the EFT and ERA. We started this
discussion, you have a copy of the presentation —
DR. WARREN: Yes, and for those of you who have the briefing book, it’s under
tab seven, the full report.
DR. SUAREZ: I don’t think I have the latest presentation here. It’s already
in the folder, so we’ll just follow the slide in the folder.
DR. WARREN: It’s not the interactive one with the last slide? Or, it is?
DR. SUAREZ: What tab is it?
DR. WARREN: Seven. And then this morning, Jeanine put a set of the slides at
your spot. So while Marietta is trying to bring up the slides, Walter, you want
to go ahead and start talking to the slides?
DR. SUAREZ: Yes. So as a subcommittee, we started the discussion of the
operating rules last Friday actually on September 16th. The purpose
of the discussion is basically to review the proposed operating rules for EFT
and ERA that have been submitted by the authoring entity that was recommended.
And I think I have the slides someplace here.
So in the first executive summary basically, the two steps that we are
following consistently now for the second time I guess in this process, with
respect to operating rules, is we are first reviewing the operating rule,
operating entity, and I’ve got it here now. So, the operating rule, review of
the operating and recommending an operating rule of authoring entity, so we
completed that for the EFT and ERA in the January to March cycle.
And now, we’re reviewing the operating rules themselves, and we’ll be making
a recommendation about that. So, that’s the subject of this meeting. This is
our second part of the meeting from last Friday that we started to review that.
So the process simply just follows the, we are in today’s meeting evaluating
this and completing the evaluation hopefully through the morning. We’ll still
have through October to discuss and finalize the decision about the operating
rules and present the operating rules to the Executive Subcommittee for
approval. And then in November, we’ll present the rules to the Full Committee
for approval. That’s the sequence.
The expectation then is through June of 2012, the interim final rules on EFT
and ERA operating rules would be developed and will be then published as
scheduled on July 1st of 2012 basically. So, that’s our sequence, I
guess the steps that we’re going to take.
We’ve mentioned in these slides that you see here were the ones that we
reviewed I believe on Friday of last week. So, we went through the discussion
of the responsibilities of the committee with respect to operating rules of
identify and review and confirm that a non-profit entity is the right entity
for the authoring of the operating rules and then determining with respect to
the operating rules whether we’re representing a consensus view of the health
stakeholders in evaluating and recommending the operating rules to the
That’s our task. This is with respect to eligibility and claims status that
we have completed already. We went through that process. We recommended the
authoring entity, and then we recommended the operating rules. And, that’s the
subject of the rules that were released in July. The deadline for comment was
September, and the final rules are expected by the end of this year.
That was for eligibility and claims status. So, we’re going through the
process for EFT and ERA. For EFT, we had an extra step which was first to
identify and recommend a standard for EFT itself. So, that’s what we did with
our first letter. We made a definition of what an EFT transaction is and then
recommended adopting a specific standard for that.
And then, the second part of the process is the identification of an
authoring entity for the EFT and ERA operating rules. And that’s what we did in
the second letter that we submitted to the Secretary was after reviewing the
applicants that we recommended naming CAQH for the authoring entity, along with
NACHA, and made a few other recommendations about the operating rule
development process. So, that’s the second step.
And now, we’re going through the third step which is reviewing the actual
operating rules. So, we talked about the, on Friday, the accomplishments of
since the last, over the last four months, with respect to the work that CAQH
CORE has done. In developing these operating rules, they have dealt numerous
A large group of participants have conducted a number of straw polls related
to the operating rules. They reviewed over a hundred EFT and ERA enrollment
forms and then developed a series of proposed operating rules and started the
vetting process, identified areas of improvement in the operating rules for CCD
Plus, the standard that is being recommended to be used.
And so, they submitted to us five operating rules for consideration
basically. One is the enrollment to ERA, to the electronic remittance advice.
The second one is an enrollment rule for EFT.
The third one is a series of rules related to the use of what is known in
the industry as CARC and RARC. We mentioned those in the call, the Claim
Adjustment Reason Codes and Remittance Advice Remark Codes.
Another rule related to the re-association between the EFT and the ERA and
then a rule related to something related to the 835. Those were the five rules.
And we looked, the rules basically describe, each of the rules describe
consistently these four areas: the scope, the high-level requirement, the
problem addressed by the rule, and the potential impact that they will have.
So, we went through the review of the, I think we went through the review of
the enrollment of the EFT and the enrollment of ERA rules. And these are the
same slides that we used last Friday, so I don’t think we need to repeat these
basically. We already went through them and talked about them.
We looked at the document, and there were a few comments made by people
during the call related to, one of the elements was that in the rules, there is
a, for each data element, it determined whether the data element is required or
optional is as its naming the operating rule. And in some instances, the
optionality of the actual data element looked like it was optional if a certain
aspect was met, a certain condition was met. So, it was more situational in
And in other instances, it was truly optional. So, the subcommittee members
on the last call had some questions about that, the optionality and the meaning
of the optionality of those data elements and to what extent, again, some of
those can be converted into something more specific to avoid a lot of the
customization of the application of the operating rule.
So, EFT enrollment was one. The other one was the ERA enrollment rule. And
we again reviewed that rule as well and had kind of a similar comment, for it’s
all the same general content and characteristics.
So, we also reviewed the other rules related to the re-association. I’m
skipping the CARC and RARC because I think that’s the one I think we wanted to
spend a lot more time. But, we also talked about the rule related to
re-associating the EFT and the ERA and then sort of the fact that the rule
addresses providing receipt of the core required minimum CCD Plus data elements
that are required to be able to successfully re-associate the EFT that it needs
in from the payer bank to the provider bank, and then the provider bank
communicating that to the provider.
With the ERA, that is sent from the health fund generally directly to the
provider on a different stream. Some of the timing of that stream was also
mentioned. It’s also covered in the operating rules of the model phase that the
different between the two messages should have and the window of time I guess
between the two to make sure that there isn’t like months or weeks between the
two in terms of lag time.
So, we cover that rule as well. And then, we started to talk about the CARC
and RARC rules. And this particular rule, basically, included a series of
scenarios basically where the CARC and RARC codes were looked into and agreed
as an operating rule to help define the relationship between both the CARC and
So the core participants, as I said here, submitted and reviewed several
hundreds of codes combinations for inclusion. And the idea was that this rule
would identify the maximum set of CARC and RARC and then claim adjustment group
code combinations that would be applied to relay back a denial, a claim denial
message with specifications of why the denial was done. So, they reviewed
hundreds of those and built a series of scenarios where they would apply those
agreed upon definitions of the relationship between the CARC and RARC and CA
Examples of those were, one of them was additional information required,
missing/invalid/incomplete documentation. Another one was additional
information required, missing/invalid/incomplete data from a submitted claim.
So what happens is, you know, when a payee receives a claim, they look at the
claim, and then they find that there are missing or incomplete documentation.
And then, they can send back a message with these codes that tells the
submitter, the provider, that additional information was needed and that the
claim was not processed. Bill service not covered by health plan, benefit of
bill service not separately payable. So, those were a few examples of the
scenarios that they looked into.
The problems that read by the draft rule on CARC and RARC was providers do
not receive uniform and consistent code combinations today for the same or
similar business scenarios from all plans. So you know, a health plan sends a
particular combination to tell the provider there was an invalid or missing
data element and another health plan uses a different combination for the exact
And so, the idea was to create a consistent use of the combination of these
codes in the same scenarios across all health plans. All health plans will be
using the same code combination to relay the message back to the provider about
the missing elements. And so, by virtue of that not being consistent, the
providers aren’t able to automatically close claim payment adjustments and
claim analysis accurately and respond to the needs.
Focus on business scenarios with a maximum set of code combinations that
target like 80 percent of the major provider usage problems. So, that’s the
priority because when looking at this, you know, you can spend hundreds of
hours devoted to developing standardization of code combinations on hundreds of
scenarios. But because of the short timeframe and the need to establishing
these set of rules, operating rules, for these transactions, the CAQH group and
the members decided to really focus on this business scenario that offered a
maximum set of combinations that addressed the largest proportion of issues.
The key impact begins to address really a significant industry challenge by
addressing the high volume issues so that begins to address an important
element because just like with any other standard, the operating rule will be a
moving process. It’s not going to be like we have now, set the rule, and we’re
not going to do anything with the rule.
We’re going to be in the future moving to expanding that rule to cover other
scenarios. So, this begins to address the most significant ones. And then, as
we move along into future versions of the operating rule, then other scenarios
will be covered.
Enable providers to more effectively use the remittance advice data when
definitions for claims adjustments or denials are consistent across all health
plans which we’ll be solving in better revenue cycle and cash flow management.
And require more focus on the use of standard codes, not proprietary codes that
could spill into these messages.
So, that was kind of the overview of the code structure. There is, of
course, the more detailed documentation of the code sets. And I think, let me
see, in tab seven, you have the more detailed description of the operating
rule. And then, each of the operating rules have their own, each of these rules
have their own set of documents, of course, more detailed documents.
What we have done here in this attachment is to help us look at the proposed
rules and be able to discuss and then define and make the recommendation to the
Full Committee to adopt them. We’re not going to do that today, of course,
which is going to be discussing today, listening more to the perspectives that
any of you have. We’d like to listen also from the audience and the public and
others. I think CAQH is probably going to have someone here today too. So
DR. WARREN: So let’s, I’m going to try to structure this so that we make
good use of our time. Under tab seven, you have a more thorough description of
what is in the operating rules. We’ve also given you or CORE sent to us the
links to the rules themselves so that once you take a look at our analysis
which is in the table of each of those rules, if you have any questions, you
can go directly to the source.
We’ve had a long discussion about our own ability to evaluate those rules.
They were developed by experts in the field. And so, it’s not our purview to
edit their rules. It’s our purview, did they follow the processes that they
said they would? Was it open? Was the process transparent? Is there anything in
the rules that we would find difficult for CMS to carry out? And that’s at a
high level difficult, not specific issues or anything like that.
And, we do plan on once we have, under tab seven, Walter and I have also
made some recommendations for us that I’d like some clarity on so that we could
start drafting a letter. We will have at least one more phone call to discuss
the issue and the letter before we submit it to the Executive Committee. And if
you notice, our timeline is pretty rapid. With that, I’ve got Raj in on the
comment list. Raj?
DR. CHANDERRAJ: Yes. In these rules set for additional information required
because this disturbs the workflow for a physician working to, the note that we
DR. WARREN: I don’t think these rules will interfere with the workflow of
DR. CHANDERRAJ: It does though because every day I see in my practice two or
three patients’ insurance delays the payment because they say additional
information is required. There’s no standard. The note clearly states why the
patient is acquiring certain thing, and everything is clear in the note. I have
to review the chart and then respond to that. And the payment is delayed by
more than six to eight weeks.
DR. WARREN: And these rules should help decrease that.
DR. SUAREZ: Yes, that’s the main benefit of these operating rules is to
harmonize the use of the electronic message that will come to the provider
saying I need more information so the provider’s system can generate that
quickly and send it back and the payment will be reduced. I mean the lag time
on the payment will be significantly reduced. That’s the goal.
DR. CHANDERRAJ: What I am trying to address is are the rules set for, what
additional information? What are the rules that they require? What are the
rules set for requesting a —
DR. WARREN: So, you have access to the rules. You can read them and see what
additional stuff is required. The links are in tab seven so that you can read
those because I think we do need your perspective as a physician practitioner
on how they might affect you.
It would also help us because the purpose of the rules is all payers need to
follow those so that you collect your data in one way and it goes to all payers
instead of having to have people on your staff learn what each payer wants and
produce different documents. So, that’s the purpose of this.
DR. SUAREZ: And Gwen is here. She could probably explain a little more about
MS. LOHSE: I was just going to offer if anyone on the committee wants to sit
down and has questions, we can make ourselves available.
DR. WARREN: Okay, thank you Gwen. Seth? You have your card up, magic sign?
No, that’s a past one. Okay.
MR. SOONTHORNSIMA: I understand CORE had a vote yesterday?
MS. LOHSE: It passed.
MR. SOONTHORNSIMA: It passed, so the 5/4 has passed.
MS. LOHSE: Because of the way they have voting structure, it is all or
MR. SOONTHORNSIMA: Were there any controversies or any major concerns, even
though it was a block vote, that we should hear about?
DR. SUAREZ: Yes, Gwen, if you could give us an update on the vote.
MS. LOHSE: Yes, I will try to be pretty brief. We just reviewed the vote
last night pretty late, all the comments. So, we’re trying to still analyze
them. Approximately high 70s of the entities voted, so you had a very high
percentage voting. Of that, the high 70s actually approved. Those that didn’t
approve were a mix of abstain and object, really split between.
And the comments came from entities that both approved and objected or
abstained. A large majority of them were a few entities are still hoping to do
every single CARC and RARC rule. There’s 800 codes, and there’s thousands of
combinations that you could do as a result of the codes. And the research
really focused on using several states had done research, some other entities
had done research.
So, some people are still saying, oh, can we go back to look at every code?
And there’s many examples like that, people just wanting to expand or reduce.
So, those aren’t new issues.
Two other things. I think two of the key comments are one is, we’re going to
look to ensure we spend a considerable amount of time ensuring medical and
pharmacy are really well-aligned considering the physicians’ office is dealing
with both. And as you saw, we did an MOU with NCPDP. So, we’re going to look at
that issue just one more time, not changing the scope in the requirements of
the rule, but how to make sure there’s full alignment.
And then, also looking at the concept of CORE was founded to push adoption
and implementation and track the ROI. There’s a whole model in place to bring
back the tracking, etcetera. And there’s mentions of voluntary CORE
certification. So, how can we ensure that as we work forward to both do
voluntary and mandated processes, we’re continuing to support the concept that
certification is voluntary.
So, that’s kind of a quick summary. We have documentation on the comments.
If the Committee wants us to make it available to them, we’re happy to do that.
DR. WARREN: I think once you’ve analyzed them, it would help especially
since this is the first time we’re doing this.
MS. LOHSE: Yes, absolutely.
DR. WARREN: Probably for both of us, it would help to —
DR. SUAREZ: Quick question. Could you describe, because that was one of the
big questions that came up on Friday’s call, describe each of the rules have
the detailed listing of the data elements. And the data elements are either
required or optional.
And the question was about the optional ones because there are some optional
that look like if a specific rule is met or certain elements of the rule is met
then you must do it. But in other cases, the optional was really optional. So,
the subcommittee was wondering about the meaning of that optionality and
whether there was any way to reduce the degree to which the optionality depends
on, you know, variability of —
MS. LOHSE: And, I have been reminded there are people on the phone, so this
is Gwendolyn Lohse from CAQH CORE. And, I’m the Managing Director at CORE and
the Deputy Director for CAQH just for the record.
With regard to your comment, Walter, and I’m trying to keep this brief
because I know you have a lot to do, there’s five rules as you saw. The
re-association rule really does not have any optional data elements. It’s to
match up the two transactions.
And we actually did a mapping of the two standards, the NACHA standard and
the ERA standard and said why is everyone having a problem matching them up?
And then, those elements are required because otherwise you can’t match them,
and then as we heard, the providers have a tremendous amount of problems.
The CARCs and RARCs, again, not optional, looked at tons of codes. There’s a
minimum set, so there’s not optional. The infrastructure doesn’t deal with data
elements. It’s flow of the data, so not optional to put it into this context.
So, it’s the EFT and the ERA data elements, the overwhelming for the
enrollment process to ensure you can actually do electronic transactions in
those areas. We collect the right things like the 10, but you can actually move
the data and get the provider preference and all of those items. There are a
few elements in that with regard to enrollment where there is option. And it
primarily is optional to recognize sectors of the industry and with a special
emphasis on alignment with the pharmacy industry.
So, there’s some entities that don’t offer out pharmacy, so it just would
not apply to them. There’s examples like that, so they’re not optional. It’s
more that if you do not do this type of business, it does not apply to you. And
there’s not very many, and again, it’s primarily that focus on aligning medical
and pharmacy. And I’m happy to, if you guys want a paragraph on that, to submit
MR. SOONTHORNSIMA: So Gwen, so it’s not really optionality. It’s really
MS. LOHSE: Applicability, yes. Much better said.
DR. WARREN: Okay. Mike?
DR. FITZMAURICE: A couple of questions. One is, and I’m not against
licensing fees because sometimes that’s viable for NSDO to stay in business
with. Are the CARC and RARC codes and the other codes publically available
without licensing fees?
MS. LOHSE: Great question. So, the CORE rules are free and always have been,
and they’re up on the website. Whether you participate in CORE or you do not,
you can download the rules including all the drafts. And we’ve been having open
town hall calls.
With regard to the CARCs and RARCs, and this gets a little bit confusing,
there’s two organizations separately that maintain those code sets. And they
are independent committees. So, as those code sets are maintained and we refer
to them, you can link into them. We do not maintain the code sets. The
committees maintain, the other committees maintain the code sets.
DR. FITZMAURICE: Do those committees charge for access to the codes?
MS. LOHSE: No.
DR. SUAREZ: Margaret might —
MS. LOHSE: And yes, absolutely.
MS. WEIKER: Hi. Margaret Weiker, I am the Chair of ASC 12N, which is the
insurance subcommittee. And the CARC codes, or the claim adjustment reason
codes, is a committee of volunteers that meets every Sunday three time, at the
X12 meetings to adjudicate request changes. Those codes are updated on a
website, and they are free. So, you can go to the publisher of the code set
which is WPC, to their website, and pull down a list free of charge.
They do offer some derivative type of products for charge if you want to buy
them. But, it’s not mandated that you buy them. So, that’s free.
The remittance advice remark codes is maintained by CMS. And those codes are
also free of charge from basically the same website as the claim adjustment
reason codes. Two separate committees though. And, there’s two separate
processes. Anybody can submit a change to a CARC or a RARC.
DR. FITZMAURICE: And I want to follow on, just mostly for my understanding,
I understand that these operating rules do not dictate what documentation the
payer can require for payment, nor does it express the time committed between
the receipt of an acceptable claim and the payment to be made for the claim. Is
that right? Because you can take 30 days, you can take 15 days, that’s up to
MS. LOHSE: So with regard to the payment and the remittance, one of the
rules does address that they have to be sent within a certain timeframe of each
other just as a clarification. That was a critical topic that the CORE
participants addressed. Absolutely, I think that’s a key piece of these rules.
MS. WEIKER: Mike, no operating rule and no standard addresses the payers’
adjudication policy. And I think the individual that asked questions about his
documentation earlier, that’s a policy from a payer point of view that I
require you to send me the shoe size on a podiatrist visit or something you
know. Those are payment policies that are not part of operating rules, that are
not part of standards.
Though, I think in ACA, there is a phrase about looking at those type of
things in the future of trying to standardize the editing that is done. But as
of now, those type of things are not included. So, the codes just allow you to
say you’re missing this data element or this document. But, it doesn’t say why
I need that document.
DR. WARREN: Okay, just a minute. Jim’s next. Is it just to clarify, Ob?
MR. SOONTHORNSIMA: Yes. Those are, to your point, those are oftentimes are
the state dictates the timeliness. Most states, all states do that.
MS. WEIKER: Right.
DR. SUAREZ: Every payer including Medicare, including each of the Medicaids,
including the private payers decide in their policies what they’re going to ask
for and the reason behind it. But the standards, what they allow to communicate
electronically, which is what is needed.
MR. SOONTHORNSIMA: That was my understanding.
DR. WARREN: Okay. Jim?
DR. SORACE: I was just curious. So looking forward, what kind of
infrastructure do you guys see for testing and validation and helping people
bring these rules online?
MS. LOHSE: That’s a great question and one that we’re actually extremely
committed to because if you don’t provide the glide path for the testing and
the rollout, we’re not going to be successful. So, as we look at the five
different rules just as an example, one thing with the codes, for instance, the
CARCS and RARCS, we’re going to have to be able to test for that and collect
the data because the lessons learned for that will then say, okay, how do we
potentially reduce that maximum set because some of the codes aren’t used and
there’s no reason to put the codes in the systems, we’re wasting money, let’s
reduce the set.
So, we’re thinking about how you test for the CARC and the RARC. Also for
the infrastructure rule, there’s already processes in place to test for a lot
of those that we’ve been doing before so we can apply those. For the EFT and
the ERA enrollment elements, there’s an ability to see does someone offer out
the ability to enroll. With those data elements electronically, you’re going to
be able to test for that relatively easy. They’re either going to be able to do
it or not do it.
And then finally, for that re-association rule between the two standards,
considering different methodologies to show several examples of, and maybe an
entity random selection of the two to see when, have they matched up the
elements for the rule. So, long story is yes, we’re thinking through how to
test for those. And there will be a test script for each rule by stakeholder.
And then, that analysis and the access for it will help do process improvement
as we’re moving forward. Does that answer your question?
DR. SORACE: Yes, I mean there’s always, it generates a few more though. I
try to understand myself a little bit about timeline for that.
MS. LOHSE: The current CORE voluntary certification has test scripts already
with it. So, we can build off of those because we already have lessons learned.
DR. SORACE: And that’s sort of for like practice management.
MS. LOHSE: Exactly, anyone who touches the data. So the CARC and RARC, all
this energy that the payers are going to go through to say we need to
streamline the thousands of code combinations that happen right now, many of
which aren’t used as much, if the plans put all the dollars in to do that and
then the vendors don’t change their systems, it’s never going to get to the
DR. SORACE: But it is currently available on all five rules?
MS. LOHSE: No, it is not available on all five rules. It’s available on the
current CORE rules. And then we have a draft for the five rules. So, it will be
for the health plans, the vendors including the practice management systems and
then very large providers that have their own homegrown systems.
DR. SORACE: And the last question, that will be available when do you think?
MS. LOHSE: Probably in about six, we’re estimating about six weeks. Not very
DR. WARREN: Walter?
DR. SUAREZ: Yes, so unless there are anymore questions, I know we have
another topic, I was going to suggest the following next steps. First of all,
it would be great to get a report from CAHQ CORE on the summary of the comments
and the decision and the voting that happened this week. That will be something
helpful to have.
The second thing we want to do is we’re going to convene a conference call
of the subcommittee to basically finalize and get the approval of the
recommendations to move forward to the Executive Committee. And that should
happen in the next few weeks.
The task to the subcommittee members is to review, and we’ll send an e-mail
to link you to the specific five rules because each of those is a document if
you want to see it. But as Judy pointed out, we’re really not there to edit
anything in the document. We’re really there to review it and conceptually see
if this meets the criteria that is set in statute now to evaluate the operating
So, that’s what we’re going to do at the conference call is to go through
that and decide that. And then, we’ll be able to finalize that process, make
the recommendation to the subcommittee, and then move it forward. The idea is
to complete this process as is pointed in this slide between now and the end of
We’re looking at scheduling an Executive Committee call in early November to
dispense of all the items that will be brought in front of the Full Committee
in November for approval. And this will be one of them. So, we have the next
month basically to finalize that process. Anything else, Judy?
DR. WARREN: No, I think that wraps it up. It makes me less nervous about our
timeline for this meeting. Ob, you had your hand up for one last comment.
MR. SOONTHORNSIMA: Yes, just in addition to what we’d like to get from CORE,
perhaps because, you know, you kind of talked, Jim brought it up is testing. I
was thinking broader than that. You think about what are some of the challenges
organizations would have to go through including testing and mapping all these
You know, maybe you can give us a sense of how difficult, what sort of
framework would you go through? Not right now but as a follow-up. Does it make
sense? Because you know, that will impact our recommendation perhaps.
MS. LOHSE: We’d be happy to do that, and we’ll target some of the
participants to assist with that process.
MR. SOONTHORNSIMA: That would be great. Thank you.
DR. SUAREZ: So, we’re going to move to the next item.
DR. WARREN: Yes, which is the next set of slides you were given when you
came in this morning that has Lorraine’s picture on them. I’m assuming it’s
Lorraine with her hands on her hips.
MS. DOO: I don’t think we sent it out. Do we have it on the —
DR. SUAREZ: So maybe just while Lorraine is walking to the computer there to
do the presentation, just to set up this next meeting, November 14 of the Full
Committee, November 16th or 17th I guess, we’re going to
be holding three different hearings. And, they are noted in the agenda.
So the first hearing is going to be on claim attachments. That’s Thursday,
November 17th from 1:30 to 5:00. That’s the second day of the Full
Committee. Usually the Full Committee on the second day, like today, ends
around noon. I mean, today we’re going to end at 3:00. But in November, we’re
going to look at ending at 12:30 as a Full Committee. And then at 1:30, our
claim attachment here will start.
The second hearing is on the Affordable Care Act 10109 requirements. And,
Lorraine is going to touch on those in more detail. And that’s on Friday,
November 18th in the morning. And then in the afternoon, we’ll have
the third hearing which is on the standards and operating rules maintenance
process and will be between 1:30 and 4:00.
And, we’ll talk in more detail about the content of each as we go along
here. So, we’ll start with the section 10109. Lorraine?
MS. DOO: Great, thank you. So I have two favorite phrases. One is be part of
the steamroller, or be part of the road, when I want people to get on board.
And the other is, I am the lighthouse. So this sort of makes me think that I am
the lighthouse because the yellow line stops. I’m not sure why I selected that
But anyway, this is the journey. And some parts of it are unknown because
we’re going to be exploring them with you all. So I used this slide actually at
a recent conference with Medicaid folks for their management information
systems. And this is talking about change which is what we’re all about, right?
So, it’s 81 percent of the respondents, when they asked about change said,
do I have to pick? So, I think it’s been picked for us. We’re about to have a
lot of change.
So we’ve been through this process of 1104 which is partly what we’ve been
doing, talking about the unique health plan identifier, the operating rules,
we’re going to be adopting new standards. There’s this payment policy from
Medicare which is a reiteration of what was actually adopted in 2008. And this
is a confirmation of that.
Then the compliance certification which we’ll be talking about a lot more in
terms of us actually doing the verification that health plans have certified
their compliance with the standards and operating rules that are in effect at
the time. It will be done twice. And then of course, the penalties are pretty
significant for not certifying.
And then of course, the opportunity to do audits. And, we’ve done some pilot
audits for transactions. It’s really different than doing it for privacy and
security because we’re looking at transactions. So, we’ll be doing more of
those also. So, that’s what 1104 gives us the opportunity to do.
And then, we come to this 10109 which gives us an opportunity to look kind
of at the future as Walter was talking this morning about. So, what’s our
bigger plan as we look, again, we’re all looking forward. What other things
need we be doing because we’re not really busy enough and not keeping out of
And so now we, NCVHS has an opportunity to do some collaboration with the
HIT Standards Committee. And I think we’re going to invite the Policy Committee
DR. SUAREZ: Yes, I believe actually the regulation talks –- is it only
the Standards Committee? Or, the Policy?
MS. DOO: I think so.
DR. SUAREZ: Oh, okay.
MS. DOO: But it’s totally fine for us to expand.
DR. SUAREZ: Oh, I didn’t, okay.
MS. DOO: I think, or yes, I think it says Standards Committee. So, it gives
us an opportunity to expand, if you will, the input that we’re able to get on
some opportunities for the future. And, the statute does not provide a lot of
detail or definition around these other things that we have to think about
which in some ways gives us some room to do some creative thinking.
So it talks about, you know, the basics of 10109 essentially more
uniformity, more standardization. Are there more people that we should be
bringing to the table and how can we continue to get administrative savings?
So, that’s more support for what it is we are all trying to do.
So, by January of 2012, NCVHS has to have a meeting. Yes sir?
DR. SUAREZ: I just looked at the regulation, and that says it requires HHS
to solicit no later than January 2012. Input from NCVHS, the HIT Policy
Committee and HIT Standards Committee and STOs.
MS. DOO: Oh, so it does list –-
DR. SUAREZ: It does include Policy and Standards.
MS. DOO: Oh, okay. So, I’ll correct that because I just had the standards.
DR. SUAREZ: That’s why we’re thinking of combining policy and —
MS. DOO: Okay. Excellent. So it will be both Policy and Standards as in the
statute. And so, one of the things that we have to look at is this application
process for enrollment of health plans. It’s being addressed in the operating
rules that we just heard about. But obviously, the purpose of this is how do we
get some standardization for providers so that with every health plan there’s
some consistency in what it is, the data that they’re having to report to make
it more seamless.
Also, whether the standards and operating rules should apply to other
insurance entities, such as, automobile, property and casualty, workers’ comp.
As we said yesterday, we’ve begun that conversation. They were at our hearing
in June when we were talking about preparations for 5010 and ICD-10. They are
very, very interested in being engaged. And so, that will be a big part of what
we hear about is what would the impacts be, what are you already doing, and
what would the change in that status quo result in.
The standardized forms for financial audits, we actually are going to be
really dependent on industry for getting more information about this. There
are, we know about the Medicare audits, there are Medicaid audits, there’s NAIC
audits. Providers seems to have some in abundance, there’s OIG.
So, we have been reaching out to people now to get more information about
what are these things, who is doing them, and what are the issues so that we
can have good conversation. Again, this is all the language that’s provided in
a statute. So, there isn’t substance. And what we’re trying to do, one, by
talking to industry to find out what the pain points are and then going back to
some of the committee members to get an understanding of who came forward to
say this is an issue we’d like you to try to address.
Also, talking about the transparency of the claim edits. Someone mentioned
that earlier today. Again, improvements in the standards, the generation of
operating rules is an effort at that. But, trying to understand what the pain
points are and what’s happening at the state levels already with respect to
claim edits just like it happens with prompt payment. So we’ll be having a
discussion about that.
And then, this one liner about the timeliness of payment rules, the
timeliness of payment. And so again, we’ll try to get from industry what these
pain points are so that we can begin to get some recommendations. And, I’m
assuming AHIP and Blue Cross Blue Shield and some of the other plans and
obviously providers will help us understand or help the committee understand
what these things are so that we can come up with recommendations.
So, we have the hearing in November. We’re scheduled for that. And then, the
other add-on for the committee is by 2014, so based on everything that we’ll be
knowing by then, is to come up with additional recommendations for updating and
improving the standards and operating rules, and that will be that third part
of the hearing in November which is how are we doing? What could we do better?
What can we do more of? What can we do less of in the maintenance process?
And, because we don’t have an established process for the operating rule
maintenance process, what do we need to do for that? And what are the kinds of
recommendations that NCVHS will be able to make?
These slides because I know that time is an issue, and these, all the
members have. But, this talks a little bit more about some of the issues
related to each of the items that we’ll be addressing. So again, the
application process is that right now, it’s a one-off. When you apply to a
health plan, you apply to a health plan. And the data is going to be different.
There’s no way to enter it into some central repository and be able to say, now
can you please send my stuff to Aetna and to Joe’s, you know, group health plan
and anyone else?
So given that we’re in this age of health information technology, how can we
really leverage some of the opportunities? So, this is to talk a little bit
about that. Should HIPAA apply to these other programs? What would the
I think providers have a lot of interest in that, but a claim in the
workers’ comp world, in the auto world is really different than a claim in the
medical insurance world. And so, how do we merge some of that?
These audits, as I said, we’ve been doing some research. If people in the
room or on the phone or on the committee have some particular opinions or
examples of the kinds of audits that are conducted, it would be great. I’m not
even sure a pharmacy has audits that they’re subjected to. And it would be
great to know about it.
MS. WEIKER: — has a standard for it.
MS. DOO: Okay. So, that would be great to know about that and get some
feedback on it. And again, this claim at a consistency the work that X12 is
doing, the work that CAQH CORE is doing on claims.
And terminology consistency is very helpful, but is there a way to get the
edits better communicated and more consistent and easier for the physicians to
understand? Again, always aiming for this efficiency, just constant process
improvement. And the, as we said, this nebulous timeliness of payment rule, so
we’ll try to get additional information on what was really intended by that so
that we can do a good job for NCVHS, for the Committee, and really understand
what questions need to be asked to address this item properly.
And then, this is just a status check of, so how are we doing on adopting
standards and operating rules? What needs to change? How can we be more nimble?
Can we adopt things in an easier way or enable or allow the use of updated
information or updated standards that have been approved or updated operating
rules on a voluntary basis?
Again, how can we help the industry? And what can NCVHS recommend that would
help the industry really be able to apply some of the benefits from these
And this is what’s going on in the next couple of years, so through 2014.
This is the tentative hearing schedule that Walter was talking about. I have
drafted it. When we’re a little closer on it, we’ll share it obviously. But,
we’re working through who the speakers might be, getting some interest
The claims attachment, though, just you know, HL7s workgroup has evolved
over the years. And it’s from where it was in 2005 when we proposed a standard
for claims attachments to where they are today, given the advent of electronic
health records are worlds apart. So, it will be really interesting to hear what
they’re talking about.
Medicare has been doing a pilot of the standard for electronic medical
record documentation submission for medical review. That’s been very
successful. So, they will come and talk to the group which I think will be
And the Office for the National Coordinator has expressed a lot of interest
in claims attachments, again probably related to electronic records. So, I
think it will be a pretty robust session. And of course, the HIT Policy and
Standards Committee will be very, very interested.
And then, the following day, we’ll be talking about 10109 in the morning and
really getting some input and some recommendations on that for the Committee.
And then the afternoon, we will be spending on where we go for this for
maintaining the standards and operating rules, and how do we learn from where
we are, and what some opportunities would be for the future.
So, that’s our November agenda. And any questions from the Committee?
DR. WARREN: So, any questions? Yes, Raj?
DR. CHANDERRAJ: Most of the definition is about health plans. Does it cover
entities of annuity patients having annuity insurance? And my understanding is
they are not covered by this.
MS. DOO: I’m sorry I missed the first part. Are other entities besides
medical health plans covered by HIPAA?
DR. CHANDERRAJ: Yes.
MS. DOO: Not currently. It is health plans, certain health care providers
and clearinghouses. And that’s why there’s going to be a discussion with other
insurance industries, such as, worker’s comp and automobile.
DR. CHANDERRAJ: I’m talking about the New York Life as annuity policies
floating around. And most of the patients in Nevada have annuity policies
rather than belonging to certain health plans. And are these entities covered
MS. DOO: A health plan that has group health insurance or health insurance
or medical insurance or pays for medical care is covered by HIPAA. And there’s
actually a really long list in the statute and in the regulations which we can
share with you. So, if New York Life offers auto insurance, that’s not covered.
If they offer medical, it would be.
DR. SUAREZ: Or life insurance.
MS. DOO: Or life insurance. Sorry.
DR. SUAREZ: But if they offer medical insurance, then it is covered.
MS. DOO: Yes.
DR. WARREN: Okay, we have about two to three minutes to wrap up before we
have to end so that Justine can start the Full Committee. Any comments from
people that you’d like to be sure that we hear from folks that you think are
important for these three sub-meetings that are going to occur in November?
Okay. You will be getting an e-mail from Lorraine soon with a Doodles
request so that we can schedule time for the phone call. And as we usually do
on the Doodle, we will take where most members can attend the call, we will try
to put enough options in there that we can pretty well, I think, accommodate
all of our busy schedules.
In that call, we will update you on the status of this agenda and then on
the approval of the operating rules that we went over this morning. Anything
else you want to say in closing, Walter?
DR. SUAREZ: No, but do we want to talk about the amendments to the letters
now before the Committee?
DR. WARREN: Oh. Yes, there were two amendments to the letters. One was on
the 5010 letter to change the word “enforce”, which we used I think
on two of the recommendations, to the word “adhere”. Does anybody
have objections to that change?
DR. CHANDERRAJ: It gives more latitude.
DR. WARREN: Well, the issue is that the word “enforce” was
upsetting some constituents. And that was brought to us by Bill Scanlon.
“Adhere” doesn’t add any more latitude. The Secretary is still going
to hold everybody accountable to the due date. So I mean, there’s no change in
the action, just in the way the action is phrased.
DR. SUAREZ: On that letter actually, there might be another one line that we
can add related to, and Lorraine, you can let us know if that’s appropriate.
But, we uncovered one issue with respect to the use of the new version, the
5010 version, that applies to the 835, the claim payment transaction for
pharmacy transaction related to e-prescribing.
The e-prescribing law and regulations actually inserted in those regulations
that, you know, the ERA should be done using the 835 version 4010. And so, we
were focusing on 5010 on the HIPAA regulations, but nobody really updated that.
Now, CMS is working on updating that. I’m not sure if it will occur before
January 1st, 2012.
If it doesn’t, then it creates two laws, two regulations, one that says you
should use 5010 for everything and then this other law that says you should use
4010 for this. So, one line item that we can add in the letter is to request
CMS to expedite the rulemaking for updating that particular rule.
MS. DOO: Right. And as I, I think I had sent a note. It is in this big
omnibus regulation that is in OMB now. So, it does correct it. And we just need
OMB to approve it. There’s a huge regulation going through that corrects lots
of things, and it’s with them. So, it should amend it in time.
DR. SUAREZ: Okay. And the effective date should be —
MS. DOO: It should be in January of 2012. And that would be, the goal was to
DR. WARREN: So given that, should we amend the letter?
DOO: There’s no harm, I think, to acknowledge it. I mean, the time, it’s
simply when we respond, we’ll say we had been addressing it.
DR. SUAREZ: Yes, exactly. It might be helpful. And so the other letter, if
there is nothing else on the 5010, the other letter that we need to amend a
couple of things is the acknowledgement letter.
So in the acknowledgement letter, the recommendation to adopt the ASC X12
999, I actually went back to paragraph one that does say it applies only to X12
transactions, but the actual recommendation says it applies to all HIPAA
transactions regardless of the submitted. So, we need to say in response to all
ASC X12 transactions regardless of who submitted. So we need to just make
consistent that, and we can point that out in the letter.
And the second amendment is on recommendation 1.8 which is consider
excluding real-time transactions. We talked about yesterday of modifying that,
that if they choose to do an acknowledgement on real-time transactions, then
use the acknowledgement standard because some, as I think Margaret explained,
some entities do use the acknowledgement in real-time transactions. And this
would exclude everything.
So, we’re modifying that paragraph to just say, you know, something to the
effect of if entities choose to do acknowledgement on real-time transactions,
then they use the recommended standard here. Those are the two changes that I
had on the acknowledgement letter.
DR. WARREN: I’m going to take silence as approval of the changes. And with
that, I think we are right at time. So, if there’s any unfinished business, let
Walter or I know sometime during the rest of the meeting. And, we’ll add that
to our ongoing agenda. Thank you very much. This adjourns the meeting.
(Whereupon, the subcommittee adjourned at 10:00 a.m.)