HHS Issues Proposed Rule Changing HIPAA Standards for Certain Electronic Pharmacy-Related Transactions

The U.S. Department of Health and Human Services (HHS) has issued a proposed rule that would update HIPAA’s electronic transaction standards regarding some retail pharmacy transactions related to healthcare claims. The affected retail pharmacy transactions include health care claims or equivalent encounter information, eligibility for a health plan, referral certification and authorization, and coordination of benefits. Additionally, under the proposed rule, the Medicaid pharmacy subrogation transaction standard would become applicable to all health plans. 

HIPAA requires that covered entities and their business associates follow certain rules to standardize the format and content of some electronic transactions. In response, HHS has adopted various regulations establishing and updating these standards, including 2009 regulations for electronic pharmacy-related transactions. 

The proposed rule has three goals:

  • Provide increased data exchange;
  • Improve coordination of benefits; and
  • Expand financial fields to avoid manual data entry.

The rule also would modify current retail pharmacy standards, change the use or structure of data fields, insert new segments, and add new functionality. In addition, the rule would update the standard for state Medicaid agencies seeking reimbursement from a responsible health plan and establish an initial standard for health plans. 

Comments on the proposed rule are due on January 9, 2023. Under the proposed rule, covered entities and business associates would be subject to the new standards 24 months after the new rule’s effective date. As the changes are likely to be extensive, covered entities and business associates should begin developing their implementation plans well before that deadline. 

HBL has experience in all areas of benefits and employment law, offering a comprehensive solution to all your business benefits and HR/employment needs. We help ensure you are in compliance with the complex requirements of ERISA and the IRS code, as well as those laws that impact you and your employees. Together, we reduce your exposure to potential legal or financial penalties. Learn more by calling 470-571-1007.

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Hall Benefits Law, LLC

HBL offers employers comprehensive legal guidance on benefits in mergers and acquisitions, Employee Stock Ownership Plans (ESOPs), executive compensation, health and welfare benefits, healthcare reform, and retirement plans. We counsel a wide spectrum of clients including small, mid-sized, and large companies, 401(k) investment advisors, health insurance brokers, accountants, attorneys, and HR consultants, just to name a few. HBL is passionate about advising clients, and we are dedicated to our mission: to provide comprehensive, personalized, and practical ERISA and benefits legal solutions that exceed client expectations.

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