Current through February, 2024
Section 1 Purpose
and Goals
(a) The purpose of this Rule is to
establish a process for the creation of uniform standards, including electronic
transaction standards, for health insurance claims administration and
adjudication, including but not limited to standards relating to claims forms,
patient invoices and explanation of benefits forms, the use of payment codes,
claims submission and processing procedures, and the prior authorization
process.
(b) The goals of this Rule
are set forth in 18 V.S.A. ' 9408 and Sec. 55 of Act 191 (2006):
(1) simplifying the claims administration
process for consumers, health care providers, and others so that the process is
more understandable and less time-consuming; and
(2) lowering administrative costs in the
health care financing system.
Section 2 Authority
This Rule is adopted pursuant to the authority vested in the
Commissioner by law, including but not limited to 18 V.S.A. ' 9408, 8 V.S.A. '
15(a), 18 V.S.A. ' 9404, and Sec. 55 of Act 191 (2006).
Section 3 Applicability and Scope
(a) This Rule applies to health claims,
health encounters, electronic data interchange between Health Insurers and
Health Care Providers, and to any other matter relating to claims
administration and adjudication.
(b) Except as otherwise specifically
provided, the requirements of this Rule apply to all Health Insurers and Health
Care Providers.
(c) This Rule does
not prohibit a Health Insurer from requesting additional information required
to determine eligibility of a claim under the terms of the policy or
certificate issued to the claimant, unless such request is inconsistent with
state or federal law, or with a provision of this Rule or any other applicable
rule, or with the standards adopted hereunder.
(d) This Rule does not prohibit a Health
Insurer or Health Care Provider from using alternative forms or procedures
specified in a written contract between the Health Insurer and Health Care
Provider, unless such use is inconsistent with state or federal law, or with a
provision of this Rule or any other applicable rule, or with the standards
adopted hereunder.
(e) This Rule
does not exempt a Health Insurer or Health Care Provider from any data
reporting requirements under state or federal law or regulation.
(f) In the event of a conflict between the
requirements of this Rule and federal law or regulation, the requirements of
federal law or regulation, including but not limited to the requirements of the
Health Insurance Portability and Accountability Act of 1996, as amended, shall
prevail.
(g) Unless expressly
included in a standard adopted or incorporated by reference in this Rule, the
requirements of this Rule shall not apply to long term care insurance policies,
disability policies, accident indemnity or expense policies, student indemnity
and expense policies, stand alone dental policies, or supplemental hospital
indemnity or specified disease indemnity policies.
(h) This Rule shall not apply to Health Care
Providers located outside of this state except in the following manner: a
Health Insurer shall include the standards adopted or incorporated by reference
by this Rule as conditions of contracting between the Health Insurer or its
contracted agent(s) and the out of state Health Care Provider, provided that
such standards shall not apply to Health Care Providers, as defined in Section
4(3)
(A), located outside this state, that has
fewer than 1000 inpatient discharges during the prior calendar year and such
standards shall not apply to Health Care Providers, as defined in Section
4(3)
(B) whose total dollar charges for services
to Vermont residents is less than 25 percent of its total charges during the
prior calendar year, unless a different applicability threshold is expressly
included in a standard adopted or incorporated by reference in this
Rule.
(i) This Rule shall not apply
to Health Insurers with less than five percent of the insured market in
Vermont, and to third party administrators with fewer than 5,000 covered lives
in Vermont, with respect to any market to which the standard applies, unless a
different applicability threshold is expressly included in a standard adopted
or incorporated by reference in this Rule.
Section 4 Definitions
As used in this Rule:
(1) "Commissioner" means the Commissioner of
the Department.
(2) "Department"
means the Vermont Department of Banking, Insurance, Securities and Health Care
Administration.
(3) "Health Care
Provider" means:
(A) all institutions engaged
in claims administration or claims adjudication activities with a Health
Insurer, whether public or private, proprietary or nonprofit, which offer
diagnosis, treatment, inpatient or ambulatory care to two or more unrelated
persons, and the buildings in which those services are offered. The term shall
not apply to any facility operated by religious groups relying solely on
spiritual means through prayer or healing, but includes all institutions
included in subdivision
9432(7)
of Title 18, except health maintenance organizations;
(B) a person, partnership or corporation
engaged in claims administration or claims adjudication activities with a
Health Insurer, other than a facility or institution, licensed or certified or
authorized by law to provide professional health care service in this state to
an individual during that individual's medical care, treatment or confinement;
and
(C) any agent or affiliate of
an institution or entity or person identified in subdivisions (A) and (B) of
this subdivision (3), including billing agents or other billing contractors of
such institutions or entities.
(4) "Health Claim" means a health care claim
for reimbursement or approval or any other transaction related to a health
claim between a Health Care Provider and a Health Insurer.
(5) "Health Insurer" means:
(A) any health insurance company, nonprofit
hospital or medical services corporation, or health maintenance organization
transacting health insurance business in Vermont. The requirements of this Rule
shall apply to:
(i) any Health Insurer in
connection with its insured plans;
(ii) any Health Insurer, or the controlled
affiliate of a Health Insurer, acting as a third-party administrator for an
insured or non-insured health benefit plan;
(iii) any agents or affiliates of the Health
Insurer who contract to administer the benefits covered or administered by the
Health Insurer, such as pharmacy benefit managers, radiology benefit managers,
and mental health services review agents licensed under 8 V.S.A. ' 4089a;
and
(iv) any third party
administrator that pays for, reimburses, or administers the payment or
reimbursement of health care expenses on behalf of an insured or non-insured
health benefit plan in Vermont, including any entity that pays for, reimburses,
or administers the payment or reimbursement of health care expenses on behalf
of the employee health benefit plan offered by the State of Vermont, and the
employee health benefit plan offered by any agency or instrumentality of the
state; and
(B) Medicaid,
VHAP, SCHIP and any other health benefit plan offered or administered by the
Vermont Office of Health Access, to the extent permitted by federal law or
federal authority, and to the extent not inconsistent with state budget policy
as expressly stated and enacted in an annual appropriations act.
(6) "Rule" means the
administrative rule adopted herein.
Section 5 Establishment of the Vermont Claims
Administration Collaborative
(a)
(1) The Commissioner shall contract with the
Vermont Program for Quality in Health Care, Inc. ("VPQHC"), or some other
suitable contractor designated by the Commissioner, to facilitate and provide
administrative support for a claims administration initiative to be
established, implemented, and known as the Vermont Claims Administration
Collaborative.
(2) The Vermont
Claims Administration Collaborative shall be an entity consisting of members
approved by the Commissioner who represent hospitals, health care
professionals, Health Insurers, group and individual purchasers and consumers,
and the Department. Members may appoint one or more designees from time to time
to participate in the Collaborative.
(3) The Collaborative shall recommend
measures designed to improve administrative efficiencies, to lower transaction
costs (recognizing that an initial investment may be necessary at times to
achieve these goals), to simplify the claims administration and adjudication
process, and to develop standards for the submission and processing of
claims.
(4) The Commissioner or the
Commissioner's designee, shall be a member of the Collaborative. The
Commissioner shall appoint a Chair of the Collaborative. The Commissioner, in
consultation with the members of the Collaborative, shall establish rules of
procedure for the Collaborative, including membership eligibility rules and
anti-trust guidelines.
(b) On or about January 1 of each year, the
Commissioner or the Commissioner's designee, after consultation with the
members of the Vermont Claims Administration Collaborative, shall establish an
annual agenda for the Collaborative. The Vermont Claims Administration
Collaborative shall make recommendations to the Commissioner for the adoption
by the Commissioner of claims administration and adjudication standards
pursuant to the administrative rule-making process. The Commissioner may adopt
the recommended standard with or without amendment, provided that if the
Commissioner proposes to amend the standard recommended by the Collaborative,
the Commissioner shall request the Collaborative to consider the amendment
before the standard is filed as a proposed administrative rule with the
Secretary of State under
3 V.S.A. section
838. Notwithstanding the inability of the
Collaborative to agree upon a recommendation with respect to a standard
included in the annual agenda, the Commissioner may amend or adopt a rule to
include such a standard. The Commissioner's authority to adopt rules as set
forth in this Rule is in addition to any other rule-making authority
established by law.
(c) In
developing standards for the Commissioner, the Vermont Claims Administration
Collaborative shall consult with national standard setting entities including
but not limited to Centers for Medicare and Medicaid Services (CMS), the
National Uniform Claim Form Committee, the American National Standards
Institute, the Council for Affordable Quality Healthcare's ("CAQH") Committee
on Operating Rule Exchange ("CORE") and the National Uniform Billing
Committee.
(d) Standards developed
by the Vermont Claims Administration Collaborative shall not be required for
use by Health Insurers and Health Care Providers until adopted by the
Commissioner by rule. The Collaborative and the Commissioner shall give due
consideration to the budget cycles and other implementation issues of Health
Insurers and Health Care Providers in establishing an effective date for any
adopted standard.
(e) Health
Insurers shall accept the applicable electronic data if transmitted in
accordance with the adopted electronic data interchange claims administration
standard. Health Insurers may reject electronic data if not transmitted in
accordance with the adopted electronic data interchange claims administration
standard.
Section 6
Claims Administration and Adjudication Standards
The following claims administration and adjudication
standards are hereby adopted by the Commissioner. Where standards are adopted
and incorporated by reference, such standards are available for inspection and
review at the Department's website: www.bishca.state.vt.us
(1) Standards for Explanations of Benefits
(EOBs)
(A) A sample EOB is provided. Health
Insurers that adopt this format will be in compliance with this rule. Health
Insurers shall maximize the visual clarity of the EOB to achieve optimum
readability and be consistent with H-2009-03 or any subsequent replacement
Rule(s). The font size should be as large as possible. EOBs adopted by Health
Insurers with other formats, additions to the minimum required elements or
enhancement of the terms and definitions, which are found by the Commissioner
to be confusing to the general public or do not adequately provide for visual
clarity, may be subject to review and disapproval with or without conditions by
the Department.
(B) EOB Formats
1. Health Insurers shall retain discretion to
determine the design format of their EOB forms, including but not limited to
the paper size, page layout, and the order in which the required minimum set of
elements appear on the page.
2.
Company branding and logos can be individualized and placed anywhere on the
EOB.
3. The size of the page used
to print EOBs is at the discretion of the health insurer.
(C) EOB Minimum Required Elements
All EOBs shall include the following minimum set of required
elements.
1. Service
Provider
2. Date of
Service
3. Type of Service
(Includes as a minimum, inpatient, outpatient, office visit, and pharmacy or a
detailed description of the service rendered)
4. Billed Charges
5. Not Covered/Not Allowed: with
subcategories of Not Due From Patient and Due From Patient
6. Allowed Amount
7. Other Insurance Payments
8. Co-Pay
9. Deductible
10. Deductible Met to Date
11. Co-insurance
12. Amount Paid by Plan
13. Total Due from Patient
14. Reason Code and accompanying
explanations. Reason codes and definitions of those are either the standard
HIPAA reason codes or specific to the insurer.
15. Member Service telephone number
(D) EOB Terms and Definitions
Each EOB shall be accompanied by an explanation of the terms
utilized on the EOB, either as a separate page or on the reverse side of the
EOB.
Required Term Definition
|
Required Minimum
|
1. Service Provider
|
The provider who billed your plan for the service.
|
2. Date of Service
|
The date you received the services recorded on the
statement.
|
3. Type of Service
|
No definition required
|
4. Billed Charges service
|
Amount billed for the
|
5. Not Covered
|
Any billed charges not covered by your policy
including services provided by an out-ofnetwork or nonparticipating provider.
|
6. Not Allowed your plan.
|
An adjustment made by
|
7. Not Due From Patient
|
No definition required
|
8. Due from Patient
|
No definition required
|
9. Allowed Amount
|
The amount your plan will allow for this service
|
10. Other Insurance Payments
|
Any payment made by another policy that covers you.
|
11. Co-Pay
|
The fixed dollar amount you are required to pay your
service provider for this service.
|
12. Deductible
|
An amount you must pay toward the cost of services
each Plan year before your Plan pays any benefit
|
13. Deductible Met to Date
|
No definition required
|
14. Co-insurance
|
The percentage of the allowed amount(s) that you are
required to pay your provider.
|
15. Amount Paid by Plan
|
No definition required
|
16. Total Due from Patient
|
The amount the provider may bill you.
|
17. Reason Code
|
A code that provides additional information.
|
(E)
The EOB shall account for all applicable contract benefits, including
out-of-pocket requirements and contracted provider discounts, against each
billed charge for each service on the EOB. The EOB will clearly show the amount
owed by the member to the provider, if any, for each service on the EOB and be
mathematically accurate. EOBs shall be sent to the consumer within the payment
guidelines of 18 V.S.A. '9418.
(F)
Implementation Date. This standard shall be fully implemented by all Health
Insurers on or of before Oct 1, 2010.
(G) Member Satisfaction. Each Health Insurer
shall be required to track member satisfaction with the Health Insurer's EOB.
This may be accomplished by query of their internal phone tracking system or by
survey, and shall be performed every other year. A baseline measurement of
member satisfaction shall occur no later than April 1, 2011. Results and
recommended changes shall be made available to VCAC within forty-five days of
completion of the query or survey.
(H) Office of Vermont Health Access (OVHA).
OVHA shall be excluded from the requirements of this Section (1), Standards for
EOBs, for Medicaid beneficiaries.
(2) Standards for Patient Bills
(A) Sample Patient Bills are provided.
Hospitals, Federally-Qualified Health Centers (FQHCs), Providers and Billing
Service Providers (hereinafter "Billing Entities") that adopt this format will
be in compliance with this rule. Billing Entities shall maximize the visual
clarity of Patient Bills to achieve optimum readability and be consistent with
H-2009-03 or any subsequent replacement Rule(s). The font size should be as
large as possible. Patient Bills adopted by Billing Entities with other
formats, additions to the minimum required elements or enhancement of the terms
and definitions, which are found by the Commissioner to be confusing to the
general public or do not adequately provide for visual clarity, may be subject
to review and disapproval with or without conditions by the
Department.
(B) Patient Bill
Formats
1. Billing Entities shall retain
discretion to determine the design format of their Patient Bill forms,
including but not limited to the paper size, page layout, and the order in
which the required minimum set of elements appear on the page. However, the
minimum set of elements must appear in an order, which provides for
mathematical ease in determining the amount due from the Patient.
2. Billing Entities' branding and logos can
be individualized and placed anywhere on the Patient Bills.
(C) Patient Bills Minimum Required
Elements. All patient bills shall include the following minimum set of required
elements:
1. Service Provider
2. Date of Service
3. Type of Service (Includes as a minimum,
inpatient, outpatient, office visit, and pharmacy or a detailed description of
the service rendered)
4. Billed
Charges
5. Amount Paid by
Plan
6. Plan Adjustments
7. Patient Payments
8. Due from Patient
9. When a past due amount has been referred
to collection, the bill must include a statement indicating whether the amount
due from the patient includes or excludes the amount referred to collection.
10. A statement that additional
detail is available upon request.
(D) Patient Bills Terms and Definitions. Each
Patient Bill shall be accompanied by an explanation of the terms utilized on
the Patient Bills, either as a separate page or on the reverse side of the
Patient Bills. Billing Entities may add to the required minimum definitions.
Required Term Minimum Definition
|
Required
|
1. Service Provider
|
The date you received the services recorded on this
bill.
|
2. Date of Service
|
The provider who billed your plan for the service.
|
3. Type of Service
|
No definition required
|
4. Billed Charges
|
Amount billed for the service
|
5. Amount Paid by Plan
|
No definition required
|
6. Adjustments
|
The amount that your provider and/or your plan have
agreed to discount from the billed charge.
|
7. Patient Payments
|
The dollar amount you have paid
|
8. Due from Patient
|
No definition required
|
(E)
Generation of Patient Bills.
1. Bills shall
be generated when payment is due from the patient for a new service, a past due
balance, or both.
2. The Minimum
Required Elements shall appear on the Patient Bills for any new service that
has been provided.
3. Any unpaid
balance for prior services shall appear on the bill.
4. Billing Entities that on the effective
date of the Rule, bill separately for professional and institutional services
or bill for each encounter may continue to do so.
(F) Implementation Date. This standard shall
be fully implemented in two stages. All Hospitals, FQHCs and provider practices
with three or more licensed health care practitioners shall implement these
standards on or before January 1, 2011. All other providers shall implement
these standards on or before July 1, 2011. The Department may grant a waiver to
extend the implementation deadline, on an individual basis, if a provider or
facility is not reasonably able to implement the requirements within the
specified timeframe.
(3)
Standards for Member Identification Cards (ID Cards)
(A) Applicability
1. These standards shall apply to all health
insurers for medical and mental health services, with the exception of specific
policies referenced in this Rule H-2008-04, and dental and vision
policies.
2. The standards shall
also apply to health benefit plans offered or dministered by the Office of
Vermont Health Access (OVHA), with the exception of effective date, group or
account number, and co-pay elements.
3. ID Cards issued by insurers for medical
and mental health services, and health benefit plans administered by OVHA,
shall comply with Health Insurance Portability and Accountability Act of 1996's
ID Card requirements or any other related federal or state
regulation.
(B) Minimum
Required ID Card Elements All ID cards shall include the set of required
elements shown below. Health insurers may enhance ID Cards by including
additional elements or information to the required set of elements listed
below, at their discretion.
1. Member
name
2. Member identification
number
3. Effective date (date of
current policy, most recent change to the policy or anniversary date of the
group, as appropriate to each health insurer)
4. Group or account number
5. Payer billing address
6. Customer service telephone number and
other phone numbers as appropriate to facilitate provision of care
7. (e.g. pharmacy benefits,
pre-certification, mental health/substance abuse)
Visit co-payments are required, when contractually
applicable, for at least primary care office visits, specialist office visits
and hospital emergency room visits.
(C) Effective Date
These ID Card requirements shall be effective upon policy
renewal, or upon any request for an ID Card replacement, on or after April 1,
2010.
(4)
Standards for Mid Level Practitioner Billing:
Health Insurers shall accept claims submitted directly by
Physician Assistants or Nurse Practitioners who are billing within the scope of
their licensure or certification. All Health Insurers shall implement this
procedure on or before July 1, 2010.
(5) Standards for Web-Based Prior Approval:
(A) These requirements shall apply to all
services for which a Health Insurer requires Prior Approval.
(B) Providers are required to use the
web-based system to request prior authorizations, however the insurer shall
maintain a parallel backup system for providers that do not have an adequate
infrastructure for access to web-based prior authorization systems.
(C) Health Insurers shall provide 24-hour
turn around time for entry of decisions into its claim processing
system.
(D) Health Insurers shall
provide the Department of Banking, Insurance, Securities and Health Care
Administration on a yearly basis, beginning July 1 2011, with the percentage of
prior approvals completed utilizing their web- based prior approval
systems
(E) Omitted
(F) Implementation date: January 1, 2011. The
Department may grant a waiver to extend the implementation deadline, on an
individual basis, if a Health Insurer is not reasonably able to implement the
requirements within the specified timeframe.
Section 7 Enforcement
The Commissioner may enforce a violation of a provision of
this Rule in accordance with
18 V.S.A. section
9412,
8 V.S.A.
section 3661, and any other enforcement authority conferred on the Commissioner
by law.
Section 8 Amendment
of Regulation 934
BISHCA Regulation 93-4, "Uniform Claim Forms and Uniform
Standards and Procedures for Processing" will be amended as Section
6 standards
are adopted.
Section 9
Effective Date
This Rule shall take effect on April 21, 2009.
Previously amended effective February 1, 2010.
Amended effective April 1, 2010.
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