Health Care Administrative Simplification

Health care is a more than $35 billion per year enterprise in Minnesota, generating millions of administrative transactions between health care providers, payers, intermediaries, and vendors. The Health Care Administrative Simplification Act (ASA) of 1994, Minnesota Statutes, sections 62J.50 – 62J.61, was passed to bring about greater standardization of health care administrative transactions and more electronic exchange of administrative data, to reduce administrative costs and burden.

The Minnesota Department of Health (MDH) Health Policy Division, in collaboration with advisory and standards-setting organizations, is implementing the ASA as part of ongoing efforts to streamline and simplify health care administration.

The federal Centers for Medicare & Medicaid Services (CMS) has recently issued two notices of proposed rulemaking (NPRM) of possible interest. CMS is seeking public comments on both of the NPRM. The AUC will not be submitting comments but members and interested parties are encouraged to review the NPRM and to submit their own comments if desired and as instructed in the NPRM.

• Notice of Proposed Rulemaking (NPRM) CMS-0056-P

  Title of proposed rule: Administrative Simplification: Modifications of Health Insurance Portability and Accountability Act of 1996 (HIPAA) National Council for Prescription Drug Programs (NCPDP) Retail Pharmacy Standards; and Adoption of Pharmacy Subrogation Standard

  What This Proposed Rule Would Do

  This proposed rule, if finalized, would modify the currently adopted National Council for Prescription Drug Programs (NCPDP) D.0 standard to the Telecommunications Standard Implementation Guide Version F6 (F6) and Batch Standard Implementation Guide Version 15, and adopt the NCPDP Batch Standard Subrogation Implementation Guide Version 10. The proposed rule would also broaden the applicability of the Medicaid pharmacy subrogation transaction to all health plans. To that end, the rule would rename and revise the definition of the transaction and adopt an updated standard, which would be a modification for state Medicaid agencies and an initial standard for all other health plans.

  Public Comment Period

  There is a 60-day public comment period for this rule, which closes on January 9, 2023. Instructions for submitting comments can be found at Notice of Proposed Rulemaking (NPRM) CMS-0056-P.

• Notice of Proposed Rulemaking (NPRM) CMS–0057–P (PDF)

  Title of proposed rule: CMS Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Advancing Interoperability and Improving Prior Authorization Processes for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children’s Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally Facilitated Exchanges, Merit-Based Incentive Payment System (MIPS) Eligible Clinicians, and Eligible Hospitals and Critical Access Hospitals in the Medicare Promoting Interoperability Program

  CMS proposes to modernize the health care system by requiring certain payers to implement an electronic prior authorization process, shorten the time frames for certain payers to respond to prior authorization requests, and establish policies to make the prior authorization process more efficient and transparent. The rule also proposes to require certain payers to implement standards that would enable data exchange from one payer to another payer when a patient changes payers or has concurrent coverage, which is expected to help ensure that complete patient records would be available throughout patient transitions between payers.

  CMS proposals include requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization, as well as requirements for certain payers to include a specific reason when denying requests, publicly report certain prior authorization metrics, and send decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests.

  In addition, this proposed rule would add a new Electronic Prior Authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category.

  Public Comment Period: There is a 90-day public comment period for this rule, which closes on March 13, 2023. Instructions for submitting comments can be found at Notice of Proposed Rulemaking (NPRM) CMS–0057–P (PDF)

Due to the competing demands of the COVID pandemic, the AUC is suspending activities and meetings through at least the first quarter of 2022. There are currently no AUC meetings scheduled for 2022 and meeting information will be added when available.