Prior Authorization Legislation and the X12 Winter Meeting

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As an attendee of the X12 Winter Meeting this January, I noticed a difference compared to previous conferences. This year the primary focus was legislation, reviving past and pending transactions and standards legislation, and creating new legislative initiatives. There was discussion around the 5010 Standard currently in place that was mandated 13 years ago. That Standard is 20 years old now and is required only for a limited number of transactions.

UHIN Comments and the Path Forward

UHIN has spent a lot of time developing comments and reviewing the different options for moving forward with the currently pending version of the proposed rule for pre-auth for the 6020 Standard. That rule is officially known as “Administrative Simplification: Adoption of Standards for Health Care Attachments Transactions and Electronic Signatures, and Modification to Referral Certification and Authorization Transaction Standard.”

X12, WEDI, and Cooperative Exchange have each proposed solutions to help move this forward. What has been clear from all the industry groups is without a mandate, standards are further delayed, and if history repeats itself, the current proposed change will likely be out of date before it can be mandated.

How Payers Could Get Ahead of the Curve

Understandably, there’s hesitation to adopt a rule that’s not yet mandated. The current discussion would mandate the 6020 standard that is currently part of the proposed rule. However, payers may want to consider whether beginning implementation anyway could be the right course for them. There are advantages to doing so, including allowing operations to track closer to what we believe are best practices for your business. A methodology pivot may be necessary after the final rule is in place, but you’d be ahead of the curve.

In its fact sheet on the rule, CMS cites research by CAQH, which finds healthcare industry savings of $828 million per year could be achieved from the adoption of automated electronic processing of claims, including prior-auth and attachments. Of course, an industry-wide standard is a key pillar in supporting automation.

Clarification on Paper Claims

The federal government appears to be using prior-auth as a carrot to encourage providers to cut the fax and snail mail cords. CMS has published a helpful fact sheet on the rule. In the FAQs, it explains that providers who submit paper requests for pre-auth to payers are not subject to this HIPAA rule but, “The provider would be a covered entity if their paper claims were submitted to a health care clearinghouse or a billing service, and, on behalf of the provider, that health care clearinghouse or the billing service transformed them into standard electronic transactions and transmitted them to a health plan.”

The comment period for the currently pending attachments and prior-auth rule for the 6020 standard will close on March 21, 2023.

Working Toward a Universal Language

The best standards are those that scale. We think the currently proposed rule is an important step toward a universal language for interchange, and we look forward to moving 278s in a standard fashion in the future.

UHIN has been implementing standards since 1999, starting with the first national standard 4010, and continues to be the leader in Utah in setting standards.  We work with both health plans and providers to better understand pending legislation and standards.

If you’re interested in the output of our committee, which sets standards for all of Utah, click here to view our library on the UHIN Knowledge Center. You can reference a variety of information, including payer responsibilities associated with the current standards.

By Boyd Kreeck, Senior Technical Business Analyst, UHIN