Provider Scores Win in Information Exchange

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An unnamed provider has scored a win for all health-care providers in the struggle with payors for patient insurance-coverage transparency, according to an article in Modern Healthcare.

The provider filed a complaint with CMS, which has enforcement authority for administrative simplification under HIPAA, against an insurer that has failed to use the ASC X12 Version 5010 standards for electronic claims transmissions and comply with ACA operating rules. The payor, which writes policies in half of the states in the U.S., agreed to make the changes.

Baltimore-area based health IT advisor Stanley Nachimson took the complaint to CMS on behalf of the unnamed provider, who Nachimson said wishes to remain anonymous. He also declined to name the payor.

Not only was the provider failing to use the new standard for electronic claims transmissions, it also was not meeting the ACA operating rules that require real-time queries to be answered within 20 seconds. When submitted in batches, eligibility requests require a next-day response.

Modern Healthcare Article