Utah Admin. Code R590-164-5 - Electronic Data Interchange Transactions
(1)
(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.
(b) In developing standards for the
commissioner, the UHIN Standards Committee shall consult with national
standard-setting entities including CMS, NUCC, ASC X12N, NCPDM, and
NUBC.
(2) The
commissioner shall incorporate a standard adopted by the UHIN Standards
Committee into rule before it is required for use by payers and
providers.
(3) A payer shall accept
the applicable electronic data if transmitted in accordance with the electronic
data interchange standard that is incorporated in rule.
(4) A payer may reject electronic data if not
transmitted in accordance with the electronic data interchange standard that is
incorporated in rule.
(5) The HIPAA
electronic data interchange standards described in this Subsection (5) and
adopted by the UHIN Standards Committee are incorporated by reference by the
commissioner and are available at https://insurance.utah.gov.
(a) "999 Implementation Acknowledgement For
Health Care Insurance Standard v3.4." The purpose of the standard is to detail
the standard transaction for the reporting of transmission receipt and
transaction or functional group X12 and implementation guide error, and adopt
the use of the ASC X12 999 transaction.
(b) "Adaptive Behavior Services/Applied
Behavior Analysis (ABA) Billing Standard" v3.1." The purpose of the standard is
to detail the billing for the transmission of ABA services.
(c) "Administrative Transaction
Acknowledgements Standard v3.1." The purpose of the standard is to create a
process for acknowledging all electronic transactions between trading partners
based on the communication, syntax, semantic, and business process
specifications.
(d) "Anesthesia
Standard v3.1." The purpose of the standard is to standardize the transmission
of anesthesia data for health care services. The standard does not alter any
contractual agreement between providers and payers.
(e) "Benefits Enrollment and Maintenance
Standard v3.1." The purpose of the standard is to detail the standard
transactions for the transmission of health care benefits enrollment and
maintenance.
(f) "Claim
Acknowledgement Standard v3.2." The purpose of the standard is to provide a
standardized claim acknowledgement in response to a claim submission, which is
used to report on the status of a claim or encounter at the pre-adjudication
processing stage, for example, before the payer is legally required to keep a
history of the claim or encounter.
(g) "Claim Status Inquiry and Response
Standard v3.2." The purpose of the standard is to detail the standard
transactions for the transmission of health care claim status inquiries and
response, allow the provider to reduce the need for claim follow-up, and
facilitate the correction of claims.
(h) "CMS 1500 Paper Claim Form Standard
v3.3." The purpose of the standard is to describe the standard use of each box
for print images, and its crosswalk to the HIPAA 837 005010X222A1 Professional
implementation guide.
(i)
"Coordination of Benefits Standard v3.2." The purpose of the standard is to
streamline the coordination of benefits process between payers and providers or
payer to payers, define the data to be exchanged for coordination of benefits,
and to increase effective communications.
(j) "Dental Claim Billing Standard -- J430
v5." The purpose of the standard is to describe the standard use of each item
number for print images, and its crosswalk to the HIPAA 837 005010x02241A1
dental implementation guide, and adopt the American Dental Association Dental
Claim Form J43024.
(k) "Electronic
Remittance Advice Standard v3.5." The purpose of the standard is to detail the
standard transaction for the transmission of a health care remittance
advice.
(l) "Eligibility Inquiry
and Response Standard v3.3." The purpose of the standard is to detail the
standard transactions for the transmission of a health care eligibility inquiry
and response.
(m) "Health Care
Claim/Encounter Standard v3.2." The purpose of the standard is to detail the
standard transaction for the transmission of a health care claim, encounter,
and an associated transaction.
(n)
"Health Identification Card Standard v1.3." The purpose of the standard is to
standardize the patient health identification card information and address the
human-readable appearance and machine-readable information used by the
healthcare industry to obtain eligibility.
(o) "Health Plan Identifier (HPID) and Other
Entity Identifier (OEID) Standard v1.1." The purpose of the standard is to
inform providers of the HIPD and OEID and their usage within the administrative
transactions.
(p) "Home Health
Standard v3.1." The purpose of the standard is to provide a uniform standard of
billing for a home health care claim and encounter.
(q) "ICD-10 Standard v1.2." The purpose of
the standard is to create the business requirement for a payer and a provider
to implement the International Classification of Diseases 10th Revisions,
ICD-10, within the administrative transaction.
(r) "Individual Name Standard v2.1." The
purpose of the standard is to provide guidance for entering names into
provider, payer, or sponsor systems for a patient, enrollee, and any other
person associated with a record.
(s) "Metabolic Dietary Products Standard
v2.1." The purpose of the standard is to provide a uniform standard for the
billing of a metabolic dietary product.
(t) "NPI and Atypical Provider Standard
v3.1." The purpose of the standard is to inform a provider of the national
provider identifier requirements and the usage within a transaction.
(u) "Pain Management Standard v3.1." The
purpose of the standard is to provide a uniform method of submitting a pain
management claim, encounter, pre-authorization, and notification.
(v) "Patient Identification Number v3.0." The
purpose of the standard is to describe the standard for the patient
identification number.
(w) "Premium
Payment v3.0." The purpose of the standard is to detail the standard
transaction for the transmission of a premium payment.
(x) "Prior Authorization/Referral Standard
v3.0." The purpose of the standard is to provide general recommendations to
payers and providers about handling an electronic prior authorization and
referral.
(y) "Required Unknown
Values Standard v3.0." The purpose of the standard is to provide guidance for
the use of common data values that can be used within the HIPAA transaction
when a required data element is not known by the provider, payer, or sponsor
for a patient, enrollee, and any other person associated with the transaction.
The data values should only be used when the data is not available or known and
may not be used to replace known data.
(z) "Telehealth Standard v3.2." The purpose
of the standard is to provide a uniform standard of billing for a health care
claim and encounter delivered through telehealth.
(aa) "UB04 Form Locator Elements v3.0." The
purpose of the standard is to describe the use of each form locator in the
UB-04 claim billing form and its crosswalk to the HIPAA 837 005010X223A2
institutional implementation guide.
Notes
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