Standards for Electronic
Transactions and Code Sets
Subpart O - Enrollment and Disenrollment
in a Health Plan
§162.1501 Enrollment and disenrollment
in a health plan transaction.
The enrollment and disenrollment in a health plan transaction
is the transmission of subscriber enrollment information
to a health plan to establish or terminate insurance
coverage.
§162.1502 Standard for enrollment
and disenrollment in a health plan.
The Secretary adopts the ASC X12N 834 - Benefit Enrollment
and Maintenance, Version 4010, May 2000, Washington
Publishing Company, 004010X095 as the standard for the
enrollment and disenrollment in a health plan transaction.
The implementation specification is available at the
addresses specified in §162.920(a)(1).
Subpart P -Health Care Payment and
Remittance Advice
§162.1601 Health care payment
and remittance advice transaction.
The health care payment and remittance advice transaction
is the transmission of either of the following for health
care:
(a) The transmission of any of the following from a
health plan to a health care provider’s financial
institution:
(1) Payment.
(2) Information about the transfer of funds.
(3) Payment processing information.
(b) The transmission of either of the following from
a health plan to a health care provider:
(1) Explanation of benefits.
(2) Remittance advice.
§162.1602 Standards for health
care payment and remittance advice.
The Secretary adopts the following standards for the
health care payment and remittance advice transaction:
(a) Retail pharmacy drug claims and remittance advice.
The NCPDP Telecommunication Standard Implementation
Guide, Version 5 Release 1, September 1999, and equivalent
NCPDP Batch Standard Batch Implementation Guide, Version
1 Release 0, February 1, 1996. The implementation specifications
are available at the addresses specified in §162.920(a)(2).
(b) Dental, professional, and institutional health
care claims and remittance advice. The ASC X12N 835
- Health Care Claim Payment/Advice, Version 4010, May
2000, Washington Publishing Company, 004010X091. The
implementation specification is available at the addresses
specified in §162.920(a)(1).
Subpart Q - Health Plan Premium Payments
§162.1701 Health plan premium
payments transaction.
The health plan premium payment transaction is the
transmission of any of the following from the entity
that is arranging for the provision of health care or
is providing health care coverage payments for an individual
to a health plan:
(a) Payment.
(b) Information about the transfer of funds.
(c) Detailed remittance information about individuals
for whom premiums are being paid.
(d) Payment processing information to transmit health
care premium payments including any of the following:
(1) Payroll deductions.
(2) Other group premium payments.
(3) Associated group premium payment information.
§162.1702 Standard for health
plan premium payments.
The Secretary adopts the ASC X12N 820 - Payroll Deducted
and Other Group Premium Payment for Insurance Products,
Version 4010, May 2000, Washington Publishing Company,
004010X061 as the standard for the health plan premium
payments transaction. The implementation specification
is available at the addresses specified in §162.920(a)(1).
Subpart R - Coordination of Benefits
§162.1801 Coordination of
benefits transaction.
The coordination of benefits transaction is the transmission
from any entity to a health plan for the purpose of
determining the relative payment responsibilities of
the health plan, of either of the following for health
care:
(a) Claims.
(b) Payment information.
§162.1802 Standards for coordination
of benefits.
The Secretary adopts the following standards for the
coordination of benefits information transaction:
(a) Retail pharmacy drug claims. The NCPDP Telecommunication
Standard Implementation Guide, Version 5 Release 1,
September 1999, and equivalent NCPDP Batch Standard
Batch Implementation Guide, Version 1 Release 0, February
1, 1996. The implementation specifications are available
at the addresses specified in §162.920(a)(2).
(b) Dental claims. The ASC X12N 837 - Health Care Claim:
Dental, Version 4010, May 2000, Washington Publishing
Company, 004010X097. The implementation specification
is available at the addresses specified in §162.920(a)(1).
(c) Professional health care claims. The ASC X12N 837
- Health Care Claim: Professional, Volumes 1 and 2,
Version 4010, May 2000, Washington Publishing Company,
004010X098. The implementation specification is available
at the addresses specified in §162.920(a)(1).
(d) Institutional health care claims. The ASC X12N
837 - Health Care Claim: Institutional, Volumes 1 and
2, Version 4010, May 2000, Washington Publishing Company,
004010X096. The implementation specification is available
at the addresses specified in §162.920(a)(1).
Authority: Secs. 1171 through 1179 of the Social
Security Act (42 U.S.C. 1320d - 1320d-8), as added by
sec. 262 of Public Law 104-191, 110 Stat. 2021-2031,
and sec. 264 of Pub. L. 104-191, 110 Stat. 2033-2034
(42 U.S.C. 1320d-2 (note)).
(Catalog of Federal Domestic Assistance Program No.
93.774, Medicare--Supplementary Medical Insurance Program)
Dated: July 25, 2000
Donna Shalala
Secretary
|
