Answers about administrative simplification
What is administrative simplification?
Administrative simplification is an effort to streamline administrative processes. For example, a hospital or clinic could use the same form, or transaction, for all of its patients' various public and private insurance plans. Health care providers of all kinds could spend less time doing paperwork and more time providing care and education to their patients.
What does Senate Bill 94 do?
Senate Bill 94 created the administrative simplification initiative, giving the Oregon Department of Consumer and Business Services the authority to adopt rules and mandate new standards for the following transactions:
- Eligibility inquiry and response
- Claims submissions
- Payment and remittance advice
- Claims payment or electronic funds transfers
- Claims status inquiry and response
- Claims attachments
- Prior authorization
- Provider credentialing
The Oregon Health Leadership Council (OHLC)
is a public-private collaborative organization that is working on administrative simplification in partnership with the state.
Who needs to follow these new standards?
The standards apply to all Oregon health insurers, prepaid managed care health services organizations, third-party administrators, clearinghouses, and any other entity identified by the Oregon Department of Consumer and Business Services that processes financial and administrative transactions between a health care provider and those mentioned above.
Who's implementing the new standards?
The Oregon Legislature, through the passage of Senate Bill 94, authorized the Department of Consumer and Business Services (DCBS) to mandate uniform standards for administrative and financial transactions. The new standards are developed within the Oregon Health Leadership Council. The council is a public-private organization that works health care initiatives and is charged with developing the Oregon Companion Guides for administrative simplification. The Oregon Health Authority's Office of Health Information Technology is tasked with coordinating and communicating the new standards to the public.
The Oregon Administrative Rules (836-100-0100) adopted by DCBS regarding administrative simplification are available for review.
What's happening right now?
New standards have been developed for 270/271 eligibility transactions and 837 claims and encounter transactions.
What if I can't become compliant in time?
If you cannot meet compliance within the given time, you may write a letter to the director of the Department of Consumer and Business Services (DCBS) and request a waiver extending the timeline. Please include the following information in your letter:
- The name of the Oregon Companion Guide for which the waiver is requested.
- Whether the request is for the entire Oregon Companion Guide or for a specific segment of the Oregon Companion Guide.
- The reasons you're unable to comply. Also describe any undue hardship related to compliance.
- The timeframe for which you are requesting a waiver.
- The insurer's or entity's plan for attaining compliance during the time of the waiver.
Is the Oregon Department of Medical Assistance Programs subject to these standards?
Yes. DMAP and the Medicaid Management Information System will be compliant with the standards outlined in the Oregon Companion Guides. The department is adjusting the MMIS search function, search error reporting and other requirements to be compliant by Jan. 1, 2012.
Answers about new standards for eligibility transactions (270/271 transactions)
What is 270/271?
270/271 refers to eligibility transactions, or inquiries and responses, regarding a patient's eligibility for coverage. For example, hospitals and clinics can send an inquiry to their patient's insurance plan to see if insurance covers a certain treatment. The patient's insurance plan then sends a response confirming or denying coverage.
What are the new standards for 270/271 eligibility transactions?
There are two parts to the new standard:
- Uniform transactions. Currently, there can be differences in transaction standards used by various insurance plans, providers and others. The Oregon Companion Guides create one set of standards for all plans, hospitals and clinics to use within the state of Oregon — reducing the time spent interpreting and processing transactions.
- Switch to electronic. All payers and providers must be able to submit transactions electronically by Oct. 1, 2012.
How can I become compliant?
The Oregon Health Leadership Council created the Oregon Companion Guide so that you'll know what software updates and testing should be conducted to meet the new standards.
By when do I need to be compliant?
All insurance plans and health care providers currently submitting electronic eligibility transactions must be compliant by Jan. 1, 2012. All health insurers and providers must be able to submit transactions electronically and comply with the new standards by Oct. 1, 2012.
What changes do I need to make or expect?
This depends on if you are a provider or other health care entity. Please see the 270/271 Oregon Companion Guide for details on the changes.
What search fields are included in an eligibility inquiry (270 transaction)?
The 270/271 Oregon Companion Guide requires eligibility inquiries include the following search fields: subscriber ID, last name, first name and date of birth. Social security numbers are not included, creating a more secure system for all.
Does the 270/271 Oregon Companion Guide comply with the national standards in the HIPAA TR3 documents?
Yes. The Oregon Companion Guide only adds additional requirements to the 270/271 transactions and does not conflict with the national standards.
Does the eligibility response include patient financial responsibility information?
Yes. The 271 transaction, or eligibility response, will now include additional information on the patient's remaining deductible and out-of-pocket expenses.
Is the Oregon Department of Medical Assistance Programs subject to the 270/271 Oregon Companion Guide standards?
Yes. DMAP and the Medicaid Management Information System are subject to the requirements and will be compliant by Jan. 1, 2012.