DAR File No. 28887

Insurance, Administration

R590-164

Uniform Health Billing Rule

NOTICE OF PROPOSED RULE

DAR File No.: 28887
Filed: 07/14/2006, 01:06
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule is being changed to make definitional changes and to incorporate electronic data interchange standards into the rule.

Summary of the rule or change:

New definitions were added to Section R590-164-4 of the rule. Electronic data interchange standard descriptions and effective dates have been updated.

State statutory or constitutional authorization for this rule:

Section 31A-22-614.5

Anticipated cost or savings to:

the state budget:

There will be no cost or savings to the state budget since these changes will not create a change in the filings or fees received by the department. The changes simply incorporate standards already being used in the industry.

local governments:

The changes to the rule will have no effect on the local government since the rule relates only to the relationship between the department and its licensees.

other persons:

The changes to this rule do not have any fiscal impact, either negative or positive, on the insurance industry or the citizens of Utah. They simply incorporate into the rule standards that are already being met by the insurance industry. They do not add anything new to what is already being done.

Compliance costs for affected persons:

The changes to this rule do not have any fiscal impact, either negative or positive, on the insurance industry or the citizens of Utah. They simply incorporate into the rule standards that are already being met by the insurance industry. They do not add anything new to what is already being done.

Comments by the department head on the fiscal impact the rule may have on businesses:

The changes to this rule will have no fiscal impact on the insurance industry or any other business in Utah. D. Kent Michie, Commissioner

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Jilene Whitby at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at jwhitby@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

08/31/2006

This rule may become effective on:

09/07/2006

Authorized by:

Jilene Whitby, Information Specialist

RULE TEXT

R590. Insurance, Administration.

R590-164. Uniform Health Billing Rule.

R590-164-4. Definitions.

As used in this rule:

A. Uniform Claim Forms are defined as:

(1)(a) "UB-92 HCFA-1450" means the health insurance claim form maintained by HCFA for use by institutional care providers. Currently this form is known as the UB92.

(b) "UB-04" means the health insurance claim form maintained by NUBC for use by institutional care providers.

(2)(a) "Form HCFA-1500 (12-90)" means the health insurance claim form maintained by HCFA for use by health care providers.

(b) "Form CMS 1500 (08-05)" means the health insurance claim form maintained by NUCC for use by health care providers.

(3) "American Dental Association, 1999 Version 2000" means the uniform dental claim form approved by the American Dental Association for use by dentists.

(4) "NCPDP" means the National Council for Prescription Drug Program's Claim Form or its electronic counterpart.

B. Uniform Claim Codes are defined as:

(1) "ASA Codes" means the codes contained in the ASA Relative Value Guide developed and maintained by the American Society of Anesthesiologists to describe anesthesia services and related modifiers.

(2) "CDT Codes" means the current dental terminology prescribed by the American Dental Association.

(3) "CPT Codes" means the current physicians procedural terminology, published by the American Medical Association.

(4) "HCPCS" means HCFA's Common Procedure Coding System, a coding system that describes products, supplies, procedures and health professional services and includes, the American Medical Association's (AMA's) Physician Current Procedural Terminology, codes, alphanumeric codes, and related modifiers. This includes:

(a) "HCPCS Level 1 Codes" which are the AMA's CPT codes and modifiers for professional services and procedures.

(b) "HCPCS Level 2 Codes" which are national alphanumeric codes and modifiers for health care products and supplies, as well as some codes for professional services not included in the AMA's CPT codes.

(5) "ICDCM Codes" means the diagnosis and procedure codes in the International Classification of Diseases, clinical modifications published by the U.S. Department of Health and Human Services.

(6) "NDC" means the National Drug Codes of the Food and Drug Administration.

(7) "UB92 Codes" means the code structure and instructions established for use by the National Uniform Billing Committee.

C. "Electronic Data Interchange Standard" means the:

(1) ASC X12N standard format developed by the Accredited Standards Committee X12N Insurance Subcommittee of the American National Standards Institute and the ASC X12N implementation guides as modified by the Utah Health Information Network (UHIN) Standards Committee;

(2) other standards developed by the UHIN Standards Committee at the request of the commissioner; and

(3) as adopted by the commissioner by rule.

D. "Payer" means an insurer or third party administrator that pays for, or reimburses for the costs of health care expense.

E. "Provider" means any person, partnership, association, corporation or other facility or institution that renders or causes to be rendered health care or professional services, and officers, employees or agents of any of the above acting in the course and scope of their employment.

F. "HCFA" means the Health Care Financing Administration of the U.S. Department of Health and Human Services.

G. "UHIN Standards Committee" means the Standards Committee of the Utah Health Information Network.

H. "CMS" means the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services. CMS replaced HCFA.

I. "HIPAA" means the federal Health Insurance Portability and Accountability Act.

J. "NUBC" means the National Uniform Billing Committee.

K. "NUCC" means the National Uniform Claim Committee.

R590-164-6. Electronic Data Interchange Transactions.

A. The commissioner shall use the UHIN Standards Committee to develop electronic data interchange standards for use by payers and providers transacting health insurance business electronically. In developing standards for the commissioner, the UHIN Standards Committee shall consult with national standard setting entities including but not limited to Centers for Medicare and Medicaid Services (CMS), the National Uniform Claim Form Committee, and the National Uniform Billing Committee.

B. Standards developed and adopted by the UHIN Standards Committee shall not be required for use by payers and providers, until adopted by the commissioner by rule.

[ C. Payers shall accept the applicable electronic data if transmitted in accordance with the adopted electronic data interchange standard. Payers may reject electronic data if not transmitted in accordance with the adopted electronic data interchange standard.

] D. The following HIPAA+ electronic data interchange standards developed and adopted by the UHIN Standards Committee and adopted by the commissioner are hereby incorporated by reference with this rule and are available for public inspection at the department during normal business hours or at www.insurance.utah.gov/rules/index.htm.

(1) [Pre-HIPAA electronic data interchange standards. These standards will be superseded by HIPAA+ standards effective October 16, 2003

(a)]#1 - "Anesthesia v2.0."[.] Purpose: to standardize the transmission of anesthesia data for health care services. This standard does not alter any contractual agreement between providers and payers. Effective date: [February 1995]07-12-2003.

([b]2) #2A - "UB92 [Crosswalk]Form Locator Elements v2.0."[.] Purpose: to [provide a tool to detail the references between the UB-92 claims form and the chosen EDI transaction standard]clearly describe the use of each form locator in the UB-92 (HCFA 1450) claim billing form and its crosswalk to the HIPAA 837 004010X096 Institutional implementation guide. This standard creates a uniform billing method for institutional claims. Effective date: [February 1995]07-12-2003.

([c]3) [#2A]#2B - "[UB92 Field Data]HCFA 1500 Box Elements v2.0."[.] Purpose: to [detail the use of each ?box? in the UB-92 claim form]clearly describe the standard use of each box (for print images) and its crosswalk to the HIPAA 837 004010X098 Professional implementation guide. This standard creates a uniform billing method for professional claims. Effective date: [February 1995]07/12/03.

([d]4) [#2B - "HCFA 1500 Medical Claims". Purpose: to detail the use of each box in the HCFA 1500 claim form. Effective date: March 1995. ]#2D - "Dental Form Locator Elements v2.0." Purpose: to clearly describe the standard use of each Form Locator (for print images) and its crosswalk to the HIPAA 837 004010X097A1 Dental implementation guide. This standard creates a uniform billing method for dental claims. Effective date: 12/12/03.

([e]5) #3 - "837 Health Care Claim Standard v2.1."[.] Purpose: to detail [a]the standard transactions [and a standard use for the health care claim]for the transmission of health care claims and encounters and associated transactions in the state of Utah. Effective date: [February 1996]01/17/03.

([f]6) #4 - "Provider Remittance Advice v2.0."[.] Purpose: to detail [a standard transaction and a standard use for that transaction for the institutional and professional provider remittance advice]the standard transactions for the transmission of health care remittance advices in the state of Utah. Effective date: [September 1997]01/17/03.

([g]7) #8 - "Patient Identification Number v2.0."[.] Purpose: to [adopt the patient?s social security account number as the patient identification number standard]describe the standard for the patient identification number in Utah. Effective date: [August 1995]09/11/98.

([h]8) #9a - "Professional Common Edits". Purpose: to detail common edits used in all professional claims. Effective date: [August 1996]10/17/97.

([i]9) #10 - "Facilities Common Edits". Purpose: to detail common edits used in all facility claims. Effective date: [May 1995]9/10/99.

([j]10) #11 - "Medicaid [834 (Enrollment) Implementation Guide]Enrollment Standard v2.0."[.] Purpose: to [specify how the X12 834 transaction ("Health Care Benefits Enrollment") is to be used for the Medicaid HMO enrollment process]describe the standard for the transmission of a Medicaid enrollment transaction in the state of Utah. Effective date: [September 1995]04/12/03.

([k]11) #12 - "HCFA [1500 ]Box[es] 17 [and]/ 17A". Purpose: to [reduce or eliminate the need for attaching a paper referral form to a claim by standardizing and clarifying the use of Boxes 17 ("Referring Provider Name") and 17a ("Referring Provider ID") and their electronic equivalents]establish a standard approach to reporting referring provider name and identifier number on the HCFA 1500 claim form. This Standard also provides the cross walk to the ASC X12 837 Professional Claim version 4010A. Effective date: [February 1996]09/04/04.

([l]12) #18 - "[Functional ]Acknowledgements v2.3."[.] Purpose: to detail the [use of the functional acknowledgement transaction ]standard transaction for the reporting of transmission receipt and transaction and/or functional group X12 standard syntactical errors. This standard adopts the use of the ASC X12 997 transaction. Effective date: [January 1997]07/08/06.

([m]13) [#20 - "Claim Status - EDI Status". Purpose: to specify a new front-end claim acknowledgement transaction between payers and providers. Effective date: July 1997.

(n) #23 - "Sender and Receiver Identification in the ISA and GS Segments". Purpose: to specify the sender and receiver values in the ISA and GS (enveloping) segments.

(2) HIPAA+ electronic data interchange standards.

(a)] #20 - "Front-End Acknowledgement[,] Standard v2.2.[ Transaction]"[.] Purpose: to delineate a standardized front-end encounter acknowledgement transaction. This transaction will be used only to report on the status of a claim/encounter at the level of the payers "front end" claim/encounter edits, i.e., before the payer is legally required to keep a history of the claim/encounter. Effective date: [the earlier of October 16, 2003 or the date when trading partners implement the HIPAA 837 "Claim Transaction".]12/02/05.

([b]14) #26 - "Telehealth v2.1."[.] Purpose: to provide a uniform standard of billing for a health care claim/encounter delivered via telehealth. Two types of telehealth technology have been identified to deliver health care. [The standard includes some local modifiers that will be referenced to the appropriate national codes when the 2003 CPT/HCPCS codes are released.] Effective date: [April 16, 1999]9/13/03.

([c]15) #27 - "[Medical]Metabolic and DietaryFoods v2.1."[.] Purpose: to provide a uniform standard for billing of metabolic dietary productsfor those providers and payers that use the UB92 and the HCFA 1500 or the electronic equivalent. [The state specific Y codes will be referenced to the appropriate national codes when the 2003 CPT/HCPCS codes are released. ]Effective date: [February 12, 1999]09/11/04.

([d]16) #28 - "Home Health v2.1."[.] Purpose: to provide a uniform standard of billing for a home health care claim/encounter. [The procedure codes in this standard will be referenced to the appropriate national codes when the 2003 HIPAA codes are published. ]Effective date: [the earlier of October 16, 2003 or the date when trading partners implement the HIPAA 837 "Professional Claim Transaction"]06/12/04.

([e]17) #30 - "Pain Management". Purpose: to provide a uniform method of submitting a pain management claim/encounter, pre-authorization, and notification. Effective date: [the earlier of October 16, 2003 or the date when trading partners implement the HIPAA 837 "Professional Claim Transaction"]10/19/02.

([f]18) # 31 - "Eligibility Inquiry and Response Standard v2.2."[.] Purpose: to [mandate use of the ASC X12 270 and 271 HIPAA addenda transactions for an eligibility inquiry and response]detail the Standard transactions for the transmission of health care eligibility inquiries and responses in the state of Utah. Effective date: [the earlier of October 16, 2003 or the date when trading partners implement the transaction]06/12/04.

([g]19) #32 - "Benefits Enrollment and Maintenance Standard v2.1."[.] Purpose: to mandate the use of the ASC X12 834 HIPAA addenda transaction for health care benefits enrollment and maintenancetransactions. Effective date: [the earlier of October 16, 2003 or the date when trading partners implement the transaction]12/06/04.

([h]20) #34 - "Psychiatric Day Treatment Standard v2.0."[.] Purpose: to provide a uniform standard for submitting a psychiatric day treatment claim/encounter, pre-authorization, and notification. Effective date: [the earlier of October 16, 2003 or the date when trading partners implement the HIPAA 837 "Professional Claim Transaction"]10/09/02.

([i]21) #35 - "Prior Authorization/Referral Standard v2.0."[.] Purpose: to [mandate the use of the ASC X12 278 HIPAA addenda transaction to use for prior authorization/referral transactions](1) lay out general recommendations to payers and providers about handling the UHIN Internet based prior authorization/referral (termed the 278) system, (2) set out the minimum data set that providers will submit in the 278 request, and (3) set out the minimum data set that payers will return on the 278 response. Effective date: [the earlier of October 16, 2003 or the date when trading partners implement the transaction]10/08/02.

([j]22) #36 - "Claim Status Inquiry v2.2."[.] Purpose: to [mandate the use of the ASC X12 276/277 HIPAA addenda transaction for a claim status inquiry and response]detail the Standard transactions for the transmission of health care claim status inquiries and response in the state of Utah. Effective date: [the earlier of October 16, 2003 or the date when trading partners implement the transaction]07/08/06.

(23) #37 - "Individual Name v2.0." Purpose: to provide guidance for entering names into any Utah provider, payer or sponsor systems for patients, enrollees, as well as all other people associated with these records. Effective Date: 07/12/03.

(24) #46 - "Required 'Unknown' Values v2.0." Purpose: to provide guidance for the use of common data values that can be used within the HIPAA transactions when a required data element is not known by the provider, payer or sponsor for patients, enrollees, as well as all other people associated with these transactions. These data values should only be used when the data is truly not available or known. These values are not to be used to replace known data. Effective Date: 06/12/04.

(25) #50 - "Coordination of Benefits v2.0." Purpose: to streamline the coordination of benefits process between payers and providers. The over all goal of this standard is to define the data to be exchanged for Coordination of Benefits (COB) and increase effective communications. Effective Date: 07/08/06.

(26) #51 - "National Provider Identifier v2.1." Purpose: to describe the agreed upon requirements surrounding the National Provider Identifier and it's usage for providers and payers in the State of Utah during the transition period of May 23, 2005 through May 22, 2007. Effective Date: 07/08/06.

(27) #56 - "Professional Paper Claim Form (CMS 1500)". Purpose: to clearly describe the standard use of each Box (for print images) and its crosswalk to the HIPAA 837 004010X098A1 Professional implementation guide. Effective Date: 07/08/06.[

(3) Other Transaction Standards.]

KEY: insurance law

Date of Enactment or Last Substantive Amendment: [December 19, 2002]2006

Notice of Continuation: March 31, 2005

Authorizing, and Implemented or Interpreted Law: 31A-22-614.5

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Jilene Whitby at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at jwhitby@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.