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42 U.S. Code § 1320d-2. Standards for information transactions and data elements
(a) Standards to enable electronic exchange
(1) In generalThe Secretary shall adopt standards for transactions, and data elements for such transactions, to enable health information to be exchanged electronically, that are appropriate for—
(A)
the financial and administrative transactions described in paragraph (2); and
(B)
other financial and administrative transactions determined appropriate by the Secretary, consistent with the goals of improving the operation of the health care system and reducing administrative costs, and subject to the requirements under paragraph (5).
(2) TransactionsThe transactions referred to in paragraph (1)(A) are transactions with respect to the following:
(A)
Health claims or equivalent encounter information.
(B)
Health claims attachments.
(C)
Enrollment and disenrollment in a health plan.
(D)
Eligibility for a health plan.
(E)
Health care payment and remittance advice.
(F)
Health plan premium payments.
(G)
First report of injury.
(H)
Health claim status.
(I)
Referral certification and authorization.
(J)
Electronic funds transfers.
(3) Accommodation of specific providers
The standards adopted by the Secretary under paragraph (1) shall accommodate the needs of different types of health care providers.
(4) Requirements for financial and administrative transactions
(A) In generalThe standards and associated operating rules adopted by the Secretary shall—
(i)
to the extent feasible and appropriate, enable determination of an individual’s eligibility and financial responsibility for specific services prior to or at the point of care;
(ii)
be comprehensive, requiring minimal augmentation by paper or other communications;
(iii)
provide for timely acknowledgment, response, and status reporting that supports a transparent claims and denial management process (including adjudication and appeals); and
(iv)
describe all data elements (including reason and remark codes) in unambiguous terms, require that such data elements be required or conditioned upon set values in other fields, and prohibit additional conditions (except where necessary to implement State or Federal law, or to protect against fraud and abuse).
(B) Reduction of clerical burden
In adopting standards and operating rules for the transactions referred to under paragraph (1), the Secretary shall seek to reduce the number and complexity of forms (including paper and electronic forms) and data entry required by patients and providers.
(5) Consideration of standardization of activities and items
(A) In generalFor purposes of carrying out paragraph (1)(B), the Secretary shall solicit, not later than January 1, 2012, and not less than every 3 years thereafter, input from entities described in subparagraph (B) on—
(i)
whether there could be greater uniformity in financial and administrative activities and items, as determined appropriate by the Secretary; and
(ii)
whether such activities should be considered financial and administrative transactions (as described in paragraph (1)(B)) for which the adoption of standards and operating rules would improve the operation of the health care system and reduce administrative costs.
(B) Solicitation of inputFor purposes of subparagraph (A), the Secretary shall seek input from—
(i)
the National Committee on Vital and Health Statistics, the Health Information Technology Policy Committee, and the Health Information Technology Standards Committee; and
(ii)
standard setting organizations and stakeholders, as determined appropriate by the Secretary.