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Administrative Simplification: Certification of Compliance for Health Plans

In 2014, The Department of Health and Human Services (HHS) issued a Notice of Proposed Rule Making (NPRM) entitled “Administrative Simplification: Certification for Compliance for Health Plans”. Under this proposed rule, a controlling health plan (CHP) would be required to certify to HHS their compliance with the HIPAA-mandated standards and operating rules.


HHS defines a controlling health plan as:

  • A plan that controls its own business activities, actions, or policies
  • A plan that s controlled by an entity that is not a health plan; and if it has a sub health plan(s) exercises sufficient control over the sub health plan(s) to direct its/their business activities, actions, or policies.

Certification Requirements
This rule proposes that CHPs must submit documentation that demonstrates compliance with the adopted standards and operating rules for three electronic transactions: 

  • Eligibility for a health plan
  • Healthcare claim status
  • Healthcare electronic funds transfers (EFT) and remittance advice transactions 

The rule proposes that controlling health plans submit their certification on or before December 31, 2015. This proposed rule would also establish penalty fees for a CHP that fails to comply with the certification of compliance requirements. HHS has not yet published a final rule on the Affordable Care Act mandated health plan certification, but some CHPs are moving forward as if this requirement still applies. There are draft forms available from CAQH CORE to show the type of documentation that may be required to complete the HIPAA Credential application process. They may be found here: model compliance forms.  


Meritain Health and Our Business Partners

Meritain Health is not required to seek certification, nor as a TPA are we required to be CAQH Core certified. However, Meritain Health and our vendor partners are well-positioned to comply with the Administrative Simplification Operating Rule requirements. As your business associate, we comply with each of the HIPAA standard transactions today and our business partners are, or are becoming, CAQH CORE-certified for the eligibility and claim status operating rules. We have been assured that the platforms we use are compliant, and this information may be relied on by plans when filing their certification with HHS. 

Compliance Quarterly is being provided as an informational tool. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this publication and any attachments, Meritain Health is not exercising discretionary authority over the plan and is not assuming a plan fiduciary role, nor is Meritain Health providing legal advice.