PROVIDER PAYMENT RIGHTS
UNDER THE NEW HIPAA
HEALTHCARE EFT STANDARD &
OPERATING RULES
Priscilla Holland, AAP, CCM
Senior Director, Healthcare
Payments
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Who is NACHA?
• Standards rulemaking body
that administers the ACH
Network
• NACHA Operating Rules:
• Establish the legal foundation
for the ACH Network
• Provide a common set of rules
and formats
• Create certainty and
interoperability
• Prescribe roles and
responsibilities
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
2
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
What is the ACH Network?
• The ACH Network:
– Facilitates global commerce
by serving as a safe, efficient,
ubiquitous and high-quality
electronic payment system; it
is best known for Direct
Deposit and Direct Payment
– Is accessible via more than
13,000 U.S. financial
institutions
– More than 21 billion ACH
payments in 2012, moving
$36.9 trillion in value
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
3
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
How does this impact healthcare payments?
• The Healthcare EFT Standard is the CCD+ Addenda, an ACH
Network format.
• NACHA is the standards body for the healthcare EFT standard.
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
4
SIMPLIFYING PAYMENTS WITH THE
HEALTHCARE EFT STANDARD
What is the Healthcare EFT
Standard?
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
5
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
CCD+ Addenda: The Healthcare EFT Standard
• Allows you to directly receive health plan payments in your
bank account, like Direct Deposit
• Only payment option required to offer providers the ability to
automatically reassociate remittance information with the
payment
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
6
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Healthcare EFT & ERA Standards + Operating Rules
EFT & ERA
Standards
EFT & ERA
Operating
Rules
ACH CCD+ & X12
v5010 835
CAQH CORE EFT & ERA
Operating Rules
• EFT: NACHA
CCD+Addenda (must
contain the TRN
Reassociation Trace
Number data segment
as defined by X12
835 TR3 version
5010)
• ERA: X12 v5010 835
• Health Care Claim
Payment/Advice (835)
Infrastructure Rule
• Uniform Use of CARCs and
RARCs (835) Rule
• EFT & ERA Reassociation
(CCD+/835) Rule
• EFT Enrollment Data Rule
• ERA Enrollment Data Rule
Admin
Simplification
Together, EFT & ERA
Standards and
Operating Rules will
deliver efficiency and
consistency across
the healthcare
industry
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
7
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
“Health Care Electronic Funds Transfer and Remittance Advice Transaction”
The Healthcare EFT Standard
STAGE 1
PAYMENT INITIATION
Plan’s Bank
STAGE 2
TRANSFER OF FUNDS
STAGE 3
DEPOSIT NOTIFICATION
Provider’s Bank
Health Plan
Plan sends CCD+
Format by Agreement,
including Reassociation
TRN (Trace Number)
Segment
(ASC X12 835)
Healthcare
Provider
Provider receives
payment in bank
account, including
Reassociation TRN
(Trace Number)
Segment
(ASC X12 835) as
identified in
agreement
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
8
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Healthcare Payment Chain
Provider
1. Patient Encounter with Provider
Health Plan
1
3
2. Provider submits Claim (837) to Health Plan
3. Health Plan Adjudicates Claim
2
4. *Health Plan sends Electronic Remittance
Advice (ERA) (835) to Provider. The ERA
contains TRN Reassociation Trace Number
8
4
5
7
5. *Health Plan sends CCD+ to ODFI for Claim
Reimbursement, including a matching TRN
Reassociation Trace Number
6. ODFI Sends ACH CCD+ Addenda through
ACH Network to RDFI
6
7. RDFI receives CCD+ for Provider, deposits
credit to Provider account, and delivers the
TRN Reassociation Trace Number to
Provider
RDFI
ODFI
ACH
(Receiving Bank or Operator (Originating Bank or
8. Provider Reconciles the payment and ERA
Credit Union)
Credit Union)
by matching the TRN segment from both
*The CCD+addenda and ERA are generally not sent on the same
transactions (#4 and #5)
day. CAQH CORE operating rules establish max timeframe for
distribution.
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
9
SIMPLIFYING PAYMENTS WITH THE
HEALTHCARE EFT STANDARD
What do I need to do to comply
with legislation and operating rules
for the Healthcare EFT Standard?
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
10
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
High-Level Provider Requirements
• Enroll with individual health plans to receive EFT
• Request reassociation trace number from your bank or credit
union
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
11
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Healthcare Standard Final Rule:
Standard for Data Content of Addenda Record
• CCD+ Addenda enables
automatic reassociation of
health plan payment with
remittance information
• Your financial institution can
provide you with the
information to match the
payment with the remittance
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
12
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
CAQH CORE EFT & ERA Reassociation
Healthcare Operating Rule
CORE-required Minimum CCD+ Reassociation Data Elements
CCD+ Record
Field #
Field Name
Batch Header
Record
Detail Record
9
Effective Entry Date
6
Amount
Addenda Record
3
Payment Related Information
•
CAQH CORE EFT & ERA Reassociation Healthcare Operating Rule requires that the
Provider proactively contact its bank or credit union to receive the Core-required
Minimum CCD+ Reassociation Data Elements
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
13
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Terminology When Talking to Your Financial
Institution
• CORE EFT & ERA Operating Rules: Request the CORErequired Minimum CCD+ Reassociation Data Elements
• If your financial institution does not recognize that, try:
• ACH Payment-Related Information
• ACH Addenda Record Information
• Payment-Related Addenda Information
• NACHA Operating Rules, Subsection 3.1.5.3 require a
financial institution to provide the Payment Related
Information to the Receiver if it is requested
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
14
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Healthcare EFT Standard- Final Rule Summary
•
•
Identifies CCD+ Addenda as EFT Standard as a HIPAA Standard
Health plans are required to deliver HIPAA Standards if requested by
Provider
• 45 CFR § 162. 925
•
Does not require providers to receive health plan payments via the
EFT Standard
• However, all Medicare payments will come via the EFT Standard
•
Neither prohibits nor adopts any standards for health care EFTs
transmitted outside the ACH Network
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
15
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
When do I need to be ready to accept the Healthcare
EFT Standard?
Compliance in Effect
as of January 1, 2013
Implement by
January 1, 2014
Implement by
January 1, 2016
•
•
Eligibility for health plan
Claims status transactions
•
•
Electronic funds transfer (EFT) transactions
Health care payment and remittance advice (ERA)
transactions
•
•
•
•
•
Health claims or equivalent encounter information
Enrollment and disenrollment in a health plan
Health plan premium payments
Referral certification and authorization
Health claims attachments
Required for all HIPAA Covered Entities
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
16
SIMPLIFYING PAYMENTS WITH THE
HEALTHCARE EFT STANDARD
What are others required to do?
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
17
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Healthcare Standard – Final Rule
• Health Plans are required to:
– Certify to HHS that they are compliant with healthcare EFT standard and
healthcare EFT & ERA Operating Rules by 1/1/14
– Deliver payment via Healthcare EFT Standard (CCD+) if requested by
provider
– Offer electronic EFT enrollment
– Originate healthcare EFT and ERA within 3 business days of each other
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
18
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
NACHA Operating Rules
Requirements for Financial Institutions
Financial institutions are required to:
• Provide reassociation trace number to provider upon request
• Have a secure electronic delivery option available for the provider
• Many FIs have multiple delivery options and will work with the provider to determine
what delivery method is best for the provider
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
19
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Mandated EFT & ERA Operating Rules:
January 1, 2014 Requirements Scope
Infrastructure
Data
Content
Rule
Uniform Use of CARCs and
RARCs (835) Rule
High-Level Requirements
•
Identifies a minimum set of four CAQH CORE-defined Business Scenarios with a
maximum set of CAQH CORE-required code combinations that can be applied to
convey details of the claim denial or payment to the provider
EFT Enrollment Data Rule
•
•
•
Identifies a maximum set of standard data elements for EFT enrollment
Outlines a flow and format for paper and electronic collection of the data elements
Requires health plan to offer electronic EFT enrollment
ERA Enrollment Data Rule
•
Similar to EFT Enrollment Data Rule
•
Addresses provider receipt of the CAQH CORE-required Minimum ACH CCD+ Data
Elements required for re-association
Addresses elapsed time between the sending of the v5010 835 and the CCD+
transactions
Requirements for resolving late/missing EFT and ERA transactions
Recognition of the role of NACHA Operating Rules for financial institutions
Claim Adjustment Reason Code (CARC)
Remittance Advice Remark Code (RARC)
EFT & ERA Reassociation
(CCD+/835) Rule
•
•
•
•
Health Care Claim
Payment/Advice (835)
Infrastructure Rule
•
•
•
Specifies use of the CAQH CORE Master Companion Guide Template for the flow
and format of such guides
Requires entities to support the Phase II CAQH CORE Connectivity Rule.
Includes batch Acknowledgement requirements*
Defines a dual-delivery (paper/electronic) to facilitate provider transition to electronic
remits
* CMS-0028-IFC excludes requirements pertaining to acknowledgements.
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
20
SIMPLIFYING PAYMENTS WITH THE
HEALTHCARE EFT STANDARD
What are the benefits of using
the Healthcare EFT Standard?
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
21
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Comparison of Electronic Payment Options
Healthcare EFT Standard (via
ACH)
Virtual Card
Wire Transfer
Funds Availability
Next Day
2-3 Business days
Same Day (funds irrevocable)
Average Cost
$0.34 (any payment value)
Percentage of total payment
(avg. 3%) plus a transaction
fee
$10.73 (any payment value)
Enrollment/Acceptance
Must have a bank account
One time with each health
plan
Must have a bank account
One time with each health
plan
Risk
Very low risk with ACH credit
payment
Must have a bank account
and agreement with a
merchant card processing
provider, and point of sale
processing system/terminal
Higher risk with virtual cards
Manual processing for each
payment
None
Each payment must be
manually entered into the
POS terminal by office staff
None
Not included with payment
Manual access to each EOB
through web portal
No requirement to include
TRN Reassociation Data
Segment with payment
Reassociation with Electronic Standardized inclusion of
Remittance Information
TRN Reassociation Data
Segment in payment
Very low risk with immediate
payment
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
22
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Benefits of Choosing the Healthcare EFT Standard
• Easy, Automatic Payments – Receiving healthcare EFTs via
ACH is as quick as receiving Direct Deposit.
• Improved Cash Flow – Healthcare EFTs via ACH ensure
funds are available up to 7 days faster than with paper checks.
• Safe and Secure – Checks continue to be the dominant
payment form targeted by fraudsters. Replacing all checks
with healthcare EFTs via ACH is the single best way to combat
fraud.
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
23
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Benefits of Choosing the Healthcare EFT Standard
• Automatic Reassociation – Only healthcare EFTs via ACH
offer providers the ability to automatically reassociate
remittance information.
• HIPPA EFT Transaction– As a HIPPA transaction, under 45
CFR 162.295, providers can request delivery of the healthcare
EFT standard and health plans must comply.
• Smart, Cost-Effective Choice – The cost of claims via ACH
is, on average, only $0.34 versus $10.73 or more for other
EFT payment types.
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
24
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Facts Behind the Virtual Card
Process
• Health plans fax, email or mail the
payment information to the Provider
•
Provider will manually process the
claims payment through POS terminal
Cost Considerations
• Virtual card shifts the costs of payment
processing from the health plan to the
provider
•
Providers pay interchange fee and per
transaction charge
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
25
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Using Healthcare EFT Standard (CCD+)
Delivers Significant Cost Savings to Providers
Example of Acceptance of Different EFT Payment Types for
$2,500 claim payment
EFT Payment Type
Average Quoted Price
ACH CCD+
Must include TRN
Reassociation Data Segment
*ACH Deposit plus Addenda to
Business Account
Virtual Purchasing Card
$
0.34
No TRN Reassociation Data
Segment
**Per transaction fee
$
Interchange fee
1.90%
Wire Transfer
0.10
May include the TRN
Reassociation Data Segment
*Received wire transfer
$10.73
• Provider acceptance of ACH CCD+
addenda deposit for any value - $.34
• Payer claim payment of $2,500 made
via a Virtual Purchasing card (at
Commercial Data Rate 3 interchange)
would generate a fee of:
•
•
•
$47.50 (interchange – 1.90%)
$00.10 (transaction fee)
$47.60 Total fee to accept card payment
• Provider receipt of a wire transfer for
any value - $10.73
*The Blue Book of Bank Prices 2012-13 published by Phoenix-Hecht - https://www.phoenixhecht.com/treasuryresources/PDF/BBExecSumm.pdf
** Card fees published by MasterCard- http://www.mastercard.com/us/merchant/pdf/MasterCard_Interchange_Rates_and_Criteria.pdf
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
26
SIMPLIFYING PAYMENTS WITH THE
HEALTHCARE EFT STANDARD
How do I start using the
Healthcare EFT Standard?
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
27
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
4 Steps to Receiving Plan Payments via
the Healthcare EFT Standard
1. Contact health plan and choose the healthcare EFT standard.
2. Provide payment information to health plan.
3. Receive payments directly in your bank account.
4. Contact your bank to receive the Reassociation Trace Number directly.
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
28
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Partner with Financial Institutions to
Expand Opportunities
ACH and Treasury Management Services
Increase electronic patient payments
• Become an ACH Originator
–
Collection of outstanding Patient
obligations
Improve back office administrative processes
• Reassociate remittance information with
payment
Reduce payment risk
• Prevent unauthorized debits to account
– Debit Filter or Debit Block
– ACH Positive Pay
– Account masking (UPIC)
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
29
What Can Financial Institutions Do for Providers?
• Some financial institutions offer solutions to process claim payments
with image to EDI technology for claims payments PLUS ERA
retrieval and reassociation services.
Bank
Receivables
Service
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
30
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
Some Financial Institutions Offer EFT, ERA and
Electronic Delivery or Print/Mail Services
Providers
Claim
Disbursement
Payer
835 file
transmission
Electronic
Delivery
• View remittance
and payment
• Download
remittance (835)
• Search for
payment or claim
Single
Remittance
File
EFT to
Provider’s
Bank
Print and Mail
Check and EOP
• View payment and remittance
data in the format your
provider network receives
to enhance support
EOB to Members
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
31
SIMPLIFYING PAYMENTS WITH THE
HEALTHCARE EFT STANDARD
How can I learn more?
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
32
SIMPLIFYING PAYMENTS WITH THE HEALTHCARE EFT STANDARD
NACHA Informational Resources
Resource
Details
Healthcare Payments Resources Website
https://healthcare.nacha.org/
Health ePayments News
Quarterly newsletter
Sign up at https://healthcare.nacha.org/
Healthcare EFT Standard
Implementation Guide
•
•
•
•
What is the EFT standard?
How does it work?
How do I populate the specific fields?
What are NACHA Operating Rules and how do they
impact the standard?
https://www.nacha.org/eStore
ACH Primer for Healthcare
•
•
•
•
•
Introduces ACH payments
Defines ACH Network, participants and transaction flow
Outlines benefits of moving to EFT
Describes changes to the NACHA Operating Rules to
support healthcare EFT transactions
Compares EFT payment options
https://healthcare.nacha.org/ACHprimer
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
33
Additional Resources
• AMA EFT Toolkit - www.ama-assn.org/go/eft
• AMA Administrative Simplification LinkedIn Group
• CAQH CORE EFT & ERA Operating Rules http://www.caqh.org/CORE_phase3.php
• CAQH EFT Enrollment Database http://www.caqh.org/eft_enrollment.php
© 2013 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. This material is
not intended to provide any warranties or legal advice and is intended for educational purposes only.
34