|
Sec. 162.923 Requirements for covered entities.
(a) General rule. Except as otherwise provided in this
part, if a
covered entity conducts with another covered entity (or within the same
covered entity), using electronic
media, a transaction for which the
Secretary has adopted a standard under this part, the covered entity
must conduct the transaction as a standard
transaction.
(b) Exception for direct data entry
transactions. A
health care
provider electing to use direct data entry offered by a
health plan to
conduct a transaction for which a standard has been adopted under this
part must use the applicable data content and data condition
requirements of the standard when conducting the
transaction. The health
care provider is not required to use the format requirements of the
standard.
(c) Use of a business
associate. A covered entity may use a
business
associate, including a health care
clearinghouse, to conduct a
transaction covered by this part. If a covered entity chooses to use a
business associate to conduct all or part of a transaction on behalf of
the covered entity, the
covered entity must require the
business
associate to do the following:
(1) Comply with all applicable requirements of this part.
(2) Require any agent or subcontractor to comply with all applicable
requirements of this part.
Sec. 162.925 Additional requirements for health
plans.
(a) General rules. (1) If an entity requests a
health plan
to
conduct a transaction as a standard
transaction, the health plan must do
so.
(2) A health plan may not delay or reject a
transaction, or attempt
to adversely affect the other entity or the transaction, because the
transaction is a standard
transaction.
(3) A health plan may not reject a standard transaction on the basis
that it contains data elements not needed or used by the
health plan
(for example, coordination of benefits information).
(4) A health plan may not offer an incentive for a health care
provider to conduct a transaction covered by this part as a
transaction
described under the exception provided for in Sec. 162.923(b).
(5) A health plan that operates as a health care
clearinghouse, or
requiresan entity to use a health care clearinghouse to receive, process, or
transmit a standard transaction may not charge fees or costs in excess
of the fees or costs for normal telecommunications that the entity
incurs when it directly transmits, or receives, a standard transaction
to, or from, a health plan.
(b) Coordination of benefits. If a health plan receives a
standard
transaction and coordinates benefits with another health plan (or
another payer), it must store the coordination of benefits data it needs
to forward the standard transaction to the other
health plan (or other
payer).
(c) Code sets. A health plan must meet each of the following
requirements:
(1) Accept and promptly process any standard transaction that
contains codes that are valid, as provided in subpart J of this part.
(2) Keep code sets for the current billing period and appeals
periods still open to processing under the terms of the health plan's
coverage.
|
