A New HIPAA Federal Rule is on the Horizon for Health Plans

New HIPAA federal rule is on the horizon for health plans

In case preparing for ICD-10 and recovering from the Omnibus Rule isn’t enough, it looks like another federal rule—health plan certification for HIPAA compliance—is in the making from the Department of Health and Human Services (HHS).

The new proposed HIPAA rule, which comes as another attempt to standardize healthcare administrative transactions, is currently under development.

Recent details tell us that the health plan certification rule will require controlling health plans (CHP) to provide documentation demonstrating their compliance with certain HIPAA standards and operating rules, as adopted by the HHS.

Currently, there are two phases outlined for the health plan certification. In Phase I, the rule would affect these administrative transactions:

  • Eligibility for a health plan
  • Healthcare claim status
  • Healthcare electronic funds transfers (EFT) and remittance advice


In Phase II, the rule would affect other administrative transactions:

  • Healthcare claims or equivalent encounter information
  • Enrollment and dis-enrollment in a health plan
  • Health plan premium payments
  • Health claims attachments
  • Referral certification and authorization


The proposed certification date for Phase I is January 1, 2015, so the final rule may well be established by the end of this year. Once it’s in effect, healthcare organizations will seek certification by the Council for Affordable Quality Healthcare (CAQH).

Health plans will likely feel the largest impact of the new rule, as they can expect delays in payment if they’re not certified by the deadline.

So what you can you do now to prepare?

Health plans should discuss the rule with your operations team and conduct initial training to outline the rules and certifications with your compliance team, so they can develop a projected timeline.

Providers should stay tuned in to the progress of the rule.

Regardless of whether you’re a health plan or a provider, it’s worth your while to stay informed.