Section R590-164-5 - Electronic Data Interchange Transactions(1)(a) The commissioner shall use the UHIN Standards Committee to develop electronic data interchange standards for use by payers and providers transacting health insurance business electronically.(b) In developing standards for the commissioner, the UHIN Standards Committee shall consult with national standard-setting entities including CMS, NUCC, ASC X12N, NCPDM, and NUBC.(2) The commissioner shall incorporate a standard adopted by the UHIN Standards Committee into rule before it is required for use by payers and providers.(3) A payer shall accept the applicable electronic data if transmitted in accordance with the electronic data interchange standard that is incorporated in rule.(4) A payer may reject electronic data if not transmitted in accordance with the electronic data interchange standard that is incorporated in rule.(5) The HIPAA electronic data interchange standards described in this Subsection (5) and adopted by the UHIN Standards Committee are incorporated by reference by the commissioner and are available at https://insurance.utah.gov. (a) "999 Implementation Acknowledgement For Health Care Insurance Standard v3.4." The purpose of the standard is to detail the standard transaction for the reporting of transmission receipt and transaction or functional group X12 and implementation guide error, and adopt the use of the ASC X12 999 transaction.(b) "Adaptive Behavior Services/Applied Behavior Analysis (ABA) Billing Standard" v3.1." The purpose of the standard is to detail the billing for the transmission of ABA services.(c) "Administrative Transaction Acknowledgements Standard v3.1." The purpose of the standard is to create a process for acknowledging all electronic transactions between trading partners based on the communication, syntax, semantic, and business process specifications.(d) "Anesthesia Standard v3.1." The purpose of the standard is to standardize the transmission of anesthesia data for health care services. The standard does not alter any contractual agreement between providers and payers.(e) "Benefits Enrollment and Maintenance Standard v3.1." The purpose of the standard is to detail the standard transactions for the transmission of health care benefits enrollment and maintenance.(f) "Claim Acknowledgement Standard v3.2." The purpose of the standard is to provide a standardized claim acknowledgement in response to a claim submission, which is used to report on the status of a claim or encounter at the pre-adjudication processing stage, for example, before the payer is legally required to keep a history of the claim or encounter.(g) "Claim Status Inquiry and Response Standard v3.2." The purpose of the standard is to detail the standard transactions for the transmission of health care claim status inquiries and response, allow the provider to reduce the need for claim follow-up, and facilitate the correction of claims.(h) "CMS 1500 Paper Claim Form Standard v3.3." The purpose of the standard is to describe the standard use of each box for print images, and its crosswalk to the HIPAA 837 005010X222A1 Professional implementation guide.(i) "Coordination of Benefits Standard v3.2." The purpose of the standard is to streamline the coordination of benefits process between payers and providers or payer to payers, define the data to be exchanged for coordination of benefits, and to increase effective communications.(j) "Dental Claim Billing Standard -- J430 v4." The purpose of the standard is to describe the standard use of each item number for print images, and its crosswalk to the HIPAA 837 005010x02241A1 dental implementation guide, and adopt the ADA dental Claim Form J340.(k) "Electronic Remittance Advice Standard v3.5." The purpose of the standard is to detail the standard transaction for the transmission of a health care remittance advice.(l) "Eligibility Inquiry and Response Standard v3.3." The purpose of the standard is to detail the standard transactions for the transmission of a health care eligibility inquiry and response.(m) "Health Care Claim/Encounter Standard v3.2." The purpose of the standard is to detail the standard transaction for the transmission of a health care claim, encounter, and an associated transaction.(n) "Health Identification Card Standard v1.3." The purpose of the standard is to standardize the patient health identification card information and address the human-readable appearance and machine-readable information used by the healthcare industry to obtain eligibility.(o) "Health Plan Identifier (HPID) and Other Entity Identifier (OEID) Standard v1.1." The purpose of the standard is to inform providers of the HIPD and OEID and their usage within the administrative transactions.(p) "Home Health Standard v3.1." The purpose of the standard is to provide a uniform standard of billing for a home health care claim and encounter.(q) "ICD-10 Standard v1.2." The purpose of the standard is to create the business requirement for a payer and a provider to implement the International Classification of Diseases 10th Revisions, ICD-10, within the administrative transaction.(r) "Individual Name Standard v2.1." The purpose of the standard is to provide guidance for entering names into provider, payer, or sponsor systems for a patient, enrollee, and any other person associated with a record.(s) "Metabolic Dietary Products Standard v2.1." The purpose of the standard is to provide a uniform standard for the billing of a metabolic dietary product.(t) "NPI and Atypical Provider Standard v3.1." The purpose of the standard is to inform a provider of the national provider identifier requirements and the usage within a transaction.(u) "Pain Management Standard v3.1." The purpose of the standard is to provide a uniform method of submitting a pain management claim, encounter, pre-authorization, and notification.(v) "Patient Identification Number v3.0." The purpose of the standard is to describe the standard for the patient identification number.(w) "Premium Payment v3.0." The purpose of the standard is to detail the standard transaction for the transmission of a premium payment.(x) "Prior Authorization/Referral Standard v3.0." The purpose of the standard is to provide general recommendations to payers and providers about handling an electronic prior authorization and referral.(y) "Required Unknown Values Standard v3.0." The purpose of the standard is to provide guidance for the use of common data values that can be used within the HIPAA transaction when a required data element is not known by the provider, payer, or sponsor for a patient, enrollee, and any other person associated with the transaction. The data values should only be used when the data is not available or known and may not be used to replace known data.(z) "Telehealth Standard v3.2." The purpose of the standard is to provide a uniform standard of billing for a health care claim and encounter delivered through telehealth.(aa) "UB04 Form Locator Elements v3.0." The purpose of the standard is to describe the use of each form locator in the UB-04 claim billing form and its crosswalk to the HIPAA 837 005010X223A2 institutional implementation guide.Utah Admin. Code R590-164-5
Amended by Utah State Bulletin Number 2018-1, effective 12/8/2017Amended by Utah State Bulletin Number 2018-17, effective 8/14/2018Amended by Utah State Bulletin Number 2020-04, effective 1/22/2020Amended by Utah State Bulletin Number 2022-21, effective 10/24/2022Amended by Utah State Bulletin Number 2023-04, effective 2/8/2023Amended by Utah State Bulletin Number 2024-02, effective 1/10/2024Amended by Utah State Bulletin Number 2024-15, effective 7/23/2024