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TIMETABLES FOR
ADOPTION OF STANDARDS
SEC. 1174. (a) INITIAL
STANDARDS.--The
Secretary shall carry out section 1173 not later than 18 months after the date
of the enactment of the Health Insurance Portability and Accountability Act of
1996, except that standards relating to claims attachments shall be adopted not
later than 30 months after such date.
(b) ADDITIONS AND MODIFICATIONS TO
STANDARDS.--
(1) IN GENERAL.--Except as provided in paragraph
(2), the Secretary shall review the standards adopted under section 1173, and
shall adopt modifications to the standards (including additions to the
standards), as determined appropriate, but not more frequently than once every
12 months. Any addition or modification to a standard shall be completed in a
manner which minimizes the disruption and cost of compliance.
(2) SPECIAL RULES.--
(A) FIRST 12-MONTH PERIOD.--Except with respect
to additions and modifications to code sets under subparagraph (B), the
Secretary may not adopt any modification to a standard adopted under this
part during the 12-month period beginning on the date the standard is
initially adopted, unless the Secretary determines that the modification is
necessary in order to permit compliance with the standard.
(B) ADDITIONS AND MODIFICATIONS TO
CODE SETS.--
(i) IN GENERAL.--The Secretary shall ensure
that procedures exist for the routine maintenance, testing, enhancement,
and expansion of code sets.
(ii) Additional rules.--If a
code set is
modified under this subsection, the modified code set shall include
instructions on how data elements of health information that were encoded
prior to the modification may be converted or translated so as to preserve
the informational value of the data elements that existed before the
modification. Any modification to a code set under this subsection shall
be implemented in a manner that minimizes the disruption and cost of
complying with such modification.
REQUIREMENTS
SEC. 1175. (a) CONDUCT OF TRANSACTIONS BY
PLANS.--
(1) IN GENERAL.--If a person desires to conduct a
transaction referred to in section 1173(a)(1) with a health plan as a
standard
transaction--
(A) the
health plan may not refuse to conduct
such transaction as a standard transaction;
(B) the insurance plan may not delay such
transaction, or otherwise adversely affect, or attempt to adversely affect,
the person or the transaction on the ground that the transaction is a
standard transaction; and
(C) the information transmitted and received in
connection with the transaction shall be in the form of standard data
elements of health
information.
(2) SATISFACTION OF REQUIREMENTS.--A
health plan
may satisfy the requirements under paragraph (1) by--
(A) directly transmitting and receiving
standard data elements of health
information; or
(B) submitting nonstandard data elements to a
health care clearinghouse for processing into standard data elements and
transmission by the health care
clearinghouse, and receiving standard data
elements through the health care
clearinghouse.
(3) TIMETABLE FOR COMPLIANCE.--Paragraph (1)
shall not be construed to require a health plan to comply with any standard,
implementation specification, or modification to a standard or specification
adopted or established by the Secretary under sections 1172 through 1174 at
any time prior to the date on which the plan is required to comply with the
standard or specification under subsection (b).
(b) COMPLIANCE WITH STANDARDS.--
(1) INITIAL COMPLIANCE.--
(A) IN GENERAL.--Not later than 24 months after
the date on which an initial standard or implementation specification is
adopted or established under sections 1172 and 1173, each person to whom the
standard or implementation specification applies shall comply with the
standard or specification.
(B) SPECIAL RULE FOR SMALL
HEALTH PLANS.--In
the case of a small health plan, paragraph (1) shall be applied by
substituting '36 months' for '24 months'. For purposes of this subsection,
the Secretary shall determine the plans that qualify as small health
plans.
(2) COMPLIANCE WITH MODIFIED STANDARDS.--If the
Secretary adopts a modification to a standard or implementation specification
under this part, each person to whom the standard or implementation
specification applies shall comply with the modified standard or
implementation specification at such time as the Secretary determines
appropriate, taking into account the time needed to comply due to the nature
and extent of the modification. The time determined appropriate under the
preceding sentence may not be earlier than the last day of the 180-day period
beginning on the date such modification is adopted. The Secretary may extend
the time for compliance for small health
plans, if the Secretary determines
that such extension is appropriate.
(3) CONSTRUCTION.--Nothing in this subsection
shall be construed to prohibit any person from complying with a standard or
specification by--
(A) submitting nonstandard data elements to a
health care clearinghouse for processing into standard data elements and
transmission by the health care
clearinghouse; or
(B) receiving
standard data elements through a
health care clearinghouse.
GENERAL PENALTY
FOR FAILURE TO COMPLY WITH REQUIREMENTS AND STANDARDS
SEC. 1176. (a) GENERAL PENALTY.--
(1) IN GENERAL.--Except as provided in subsection
(b), the Secretary shall impose on any person who violates a provision of this
part a penalty of not more than $100 for each such violation, except that the
total amount imposed on the person for all violations of an identical
requirement or prohibition during a calendar year may not exceed $25,000.
(2) PROCEDURES.--The provisions of section 1128A
(other than subsections (a) and (b) and the second sentence of subsection (f))
shall apply to the imposition of a civil money penalty under this subsection
in the same manner as such provisions apply to the imposition of a penalty
under such section 1128A.
(b) LIMITATIONS.--
(1) OFFENSES OTHERWISE PUNISHABLE.--A penalty may
not be imposed under subsection (a) with respect to an act if the act
constitutes an offense punishable under section 1177.
(2) NONCOMPLIANCE NOT DISCOVERED.--A penalty may
not be imposed under subsection (a) with respect to a provision of this part
if it is established to the satisfaction of the Secretary that the person
liable for the penalty did not know, and by exercising reasonable diligence
would not have known, that such person violated the provision.
(3) FAILURES DUE TO REASONABLE CAUSE.--
(A) IN GENERAL.--Except as provided in
subparagraph (B), a penalty may not be imposed under subsection (a) if--
(i) the failure to comply was due to
reasonable cause and not to willful neglect; and
(ii) the failure to comply is corrected
during the 30-day period beginning on the first date the person liable for
the penalty knew, or by exercising reasonable diligence would have known,
that the failure to comply occurred.
(B) EXTENSION OF PERIOD.--
(i) NO PENALTY.--The period referred to in
subparagraph (A)(ii) may be extended as determined appropriate by the
Secretary based on the nature and extent of the failure to comply.
(ii) ASSISTANCE.--If the Secretary determines
that a person failed to comply because the person was unable to comply,
the Secretary may provide technical assistance to the person during the
period described in subparagraph (A)(ii). Such assistance shall be
provided in any manner determined appropriate by the Secretary.
(4) REDUCTION.--In the case of a failure to
comply which is due to reasonable cause and not to willful neglect, any
penalty under subsection (a) that is not entirely waived under paragraph (3)
may be waived to the extent that the payment of such penalty would be
excessive relative to the compliance failure involved.
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