HHS Releases Proposed Rule Regarding Certification of Compliance for Health Plans

January 2, 2014 – The Department of Health and Human Services (HHS) published a proposed rule today regarding certification (also referred to as attestation) under the Affordable Care Act, which is open for comments through March 3, 2014.

Certification Requirements

The 100-page CMS-0037-P proposed rule would require a controlling health plan (CHP) to submit information and documentation demonstrating that it is compliant with certain standards and operating rules adopted by HHS under HIPAA and would establish penalty fees for failure to comply. HHS outlines the two required methods of certification, Phase III Core Seal and HIPAA Credential, both administrated under CAQH CORE. The first step would be obtaining a HIPAA Credential and CHPs would eventually need to be certified by CAQH CORE. Page 5 of the proposed rule states:

“This proposed rule is intended to serve as an initial step toward the development of a consistent testing process that will enable entities to better achieve and demonstrate compliance with HIPAA standards and operating rules. This rule proposes that controlling health plans (CHPs) must submit certain information and documentation that demonstrates compliance with the adopted standards and operating rules for three electronic transactions: eligibility for a health plan, health care claim status, and health care electronic funds transfers (EFT) and remittance advice. Such documentation would be an indication that a CHP has completed some internal and external testing.”

CAQH Core Fees for Core Seal and HIPAA Credential

Size of Health Plan

Fee for HIPAA Credential

Fee for CAQH Phase III CORE Seal including Phase I and II Seals

Federal and State government health plans$100No charge
CAQH Member PlansNo chargeNo charge
Below $5 million in net annual revenue$100$12,000 ($4,000 per phase)
$5 million to below $25 million net annual revenue$1,000
$25 million to below $50 million net annual revenue$2,000
$50 million to below $75 million net annual revenue$4,000
$75 million and above net annual revenue$18,000 ($6,000 per phase)

Note: table found on page 44 of the proposed rule.

Deadline Delay

Per the requirements of § 162.504, CHPs are currently required to obtain their Health Plan Identifier (HPID) by November 5, 2014, with the exception of small health plans, which are required to obtain their HPID by November 5, 2015. The proposed rule seeks to postpone the HPID deadline to November 5, 2015 for all CHPs.

HHS also proposes linking the certification deadline to the date the CHP obtains its HPID, thereby postponing the deadline of the first certification of compliance requirements from December 31, 2013 to either:

  • December 31, 2015 for CHPs that obtain their HPID before 2015 or…
  • Within 365 calendar days of obtaining their HPID if their HPID is obtained in 2015 or 2016

About HCIM

Since 2000, HealthCare Information Management, Inc. (HCIM) has delivered expert consulting services and robotic automation tools for small to mid-sized healthcare payer and managed care organizations. Our concierge consulting services include everything from core claims system procurement to go live, including configuration, migration, upgrades, reporting, benefits and fee schedules, user training, and project resourcing. We also offer strategic consulting in the areas of value based payments, population health, medical management, medical loss analysis and recovery, care management, provider contract modeling, data analytics, and business process reengineering/analysis.