48.165.040 - Lead organization tasks -- Uniform standard companion document and data set.

Lead organization tasks — Uniform standard companion document and data set.

The lead organization shall:

     (1) Establish a uniform standard companion document and data set for electronic eligibility and coverage verification. Such a companion guide will:

     (a) Be based on nationally accepted ANSI X12 270/271 standards for eligibility inquiry and response and, wherever possible, be consistent with the standards adopted by nationally recognized organizations, such as the centers for medicare and medicaid services;

     (b) Enable providers and payors to exchange eligibility requests and responses on a system-to-system basis or using a payor supported web browser;

     (c) Provide reasonably detailed information on a consumer's eligibility for health care coverage, scope of benefits, limitations and exclusions provided under that coverage, cost-sharing requirements for specific services at the specific time of the inquiry, current deductible amounts, accumulated or limited benefits, out-of-pocket maximums, any maximum policy amounts, and other information required for the provider to collect the patient's portion of the bill; and

     (d) Reflect the necessary limitations imposed on payors by the originator of the eligibility and benefits information;

     (2) Recommend a standard or common process to the commissioner to protect providers and hospitals from the costs of, and payors from claims for, services to patients who are ineligible for insurance coverage in circumstances where a payor provides eligibility verification based on best information available to the payor at the date of the request; and

     (3) Complete, disseminate, and promote widespread adoption by payors of such document and data set by December 31, 2010.

[2009 c 298 § 8.]