HR 3962 IH
''SEC. 1173A" STANDARDIZE ELECTRONIC ADMINISTRATIVE TRANSACTIONS.
(a) STANDARDS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS-
(1) IN GENERAL.—The Secretary shall adopt and regularly update standards consistent with the goals described in paragraph (2).
(2) GOALS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS.— The goals for standards under paragraph (1) are that such standards shall, to the extent practicable—
(A) Be unique with no conflicting or redundant standards;
(B) Be authoritative, permitting no additions or constraints for electronic transactions, including companion guides;
(C) Be comprehensive, efficient and robust, requiring minimal augmentation by paper transactions or clarification by further communications;
(D) enable the real-time (or near real time) determination of an individual's financial responsibility at the point of service and, to the extent possible, prior to service, including whether the individual is eligible for a specific service with a specific physician at a specific facility, on a specific date or range of dates, include utilization of a machine-readable health plan beneficiary identification card or similar mechanism;
(E) Enable, where feasible, near real-time adjudication of claims;
(F) Provide for timely acknowledgment, response, and status reporting applicable to any electronic transaction deemed appropriate by the Secretary;
(G) Describe all data elements (such as reason and remark codes) in unambiguous terms, not permit optional fields, require that data elements be either required or conditioned upon set values in other fields, and prohibit additional conditions except where required by (or to implement) State or Federal law or to protect against fraud and abuse; and
(H) Harmonize all common data elements across administrative and clinical transaction standards.
(3) TIME FOR ADOPTION.—Not later than 2 years after the date of the enactment of this section, the Secretary shall adopt standards under this section by interim, final rule.
(6) IMPLEMENTATION AND ENFORCEMENT.— Not later than 6 months after the date of the enactment of this section, the Secretary shall submit to the appropriate committees of Congress a plan for the implementation and enforcement, by not later than 5 years after such date of enactment, of the standards under this section. Such plan shall include—
(A) A process and timeframe with milestones for developing the complete set of standards;
(B) A proposal for accommodating necessary changes between version changes and a process for upgrading standards as often as annually by interim, final rulemaking;
(C) Programs to provide incentives for, and ease the burden of, implementation for certain health care providers, with special consideration given to such providers serving rural or underserved areas and ensure coordination with standards, implementation specifications, and certification criteria being adopted under the HITECH Act;
(D) Programs to provide incentives for, and ease the burden of, health care providers who volunteer to participate in the process of setting standards for electronic transactions;
(E) An estimate of total funds needed to ensure timely completion of the implementation plan
(F) an enforcement process that includes timely investigation of complaints, random audits to ensure compliance, civil monetary and programmatic penalties for noncompliance consistent with existing laws and regulations, and a fair and reasonable appeals process building off of enforcement provisions under this part, and concurrent State enforcement jurisdiction.
The Secretary may promulgate an annual audit and certification process to ensure that all health plans and clearinghouses are both syntactically and functionally compliant with all the standard transactions mandated pursuant to the administrative simplification provisions of this part and the Health Insurance Portability and Accountability Act of 1996.