45 CFR 162.925 - Additional requirements for health plans.

§ 162.925 Additional requirements for health plans.

(a)General rules.

(1) If an entity requests a health plan to conduct a transaction as a standard transaction, the health plan must do so.

(2) A health plan may not delay or reject a transaction, or attempt to adversely affect the other entity or the transaction, because the transaction is a standard transaction.

(3) A health plan may not reject a standard transaction on the basis that it contains data elements not needed or used by the health plan (for example, coordination of benefits information).

(4) A health plan may not offer an incentive for a health care provider to conduct a transaction covered by this part as a transaction described under the exception provided for in § 162.923(b).

(5) A health plan that operates as a health care clearinghouse, or requires an entity to use a health care clearinghouse to receive, process, or transmit a standard transaction may not charge fees or costs in excess of the fees or costs for normal telecommunications that the entity incurs when it directly transmits, or receives, a standard transaction to, or from, a health plan.

(6) During the period from March 17, 2009 through December 31, 2011, a health plan may not delay or reject a standard transaction, or attempt to adversely affect the other entity or the transaction, on the basis that it does not comply with another adopted standard for the same period.

(b)Coordination of benefits. If a health plan receives a standard transaction and coordinates benefits with another health plan (or another payer), it must store the coordination of benefits data it needs to forward the standard transaction to the other health plan (or other payer).

(c)Code sets. A health plan must meet each of the following requirements:

(1) Accept and promptly process any standard transaction that contains codes that are valid, as provided in subpart J of this part.

(2) Keep code sets for the current billing period and appeals periods still open to processing under the terms of the health plan's coverage.

[ 65 FR 50367, Aug. 17, 2000, as amended at 74 FR 3325, Jan. 16, 2009]

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United States Code
Statutes at Large

Title 45 published on 12-Sep-2017 03:33

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 45 CFR Part 162 after this date.

  • 2015-05-29; vol. 80 # 103 - Friday, May 29, 2015
    1. 80 FR 30646 - Request for Information Regarding the Requirements for the Health Plan Identifier
      GPO FDSys XML | Text
      Request for information.
      To be assured consideration, written or electronic comments must be received at one of the addresses provided below, no later than 5 p.m. on July 28, 2015.
      45 CFR Part 162