Page:United States Statutes at Large Volume 124.djvu/173

 124 STAT. 147 PUBLIC LAW 111–148—MAR. 23, 2010 (1) DEFINITION OF OPERATING RULES.—Section 1171 of the Social Security Act (42 U.S.C. 1320d) is amended by adding at the end the following: ‘‘(9) OPERATING RULES.—The term ‘operating rules’ means the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications as adopted for purposes of this part.’’. (2) TRANSACTION STANDARDS; OPERATING RULES AND COMPLIANCE.—Section 1173 of the Social Security Act (42 U.S.C. 1320d–2) is amended— (A) in subsection (a)(2), by adding at the end the fol- lowing new subparagraph: ‘‘(J) Electronic funds transfers.’’; (B) in subsection (a), by adding at the end the following new paragraph: ‘‘(4) REQUIREMENTS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS.— ‘‘(A) IN GENERAL.—The standards and associated oper- ating rules adopted by the Secretary shall— ‘‘(i) to the extent feasible and appropriate, enable determination of an individual’s eligibility and finan- cial responsibility for specific services prior to or at the point of care; ‘‘(ii) be comprehensive, requiring minimal aug- mentation by paper or other communications; ‘‘(iii) provide for timely acknowledgment, response, and status reporting that supports a transparent claims and denial management process (including adju- dication 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 condi- tions (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.’’; and (C) by adding at the end the following new subsections: ‘‘(g) OPERATING RULES.— ‘‘(1) IN GENERAL.—The Secretary shall adopt a single set of operating rules for each transaction referred to under sub- section (a)(1) with the goal of creating as much uniformity in the implementation of the electronic standards as possible. Such operating rules shall be consensus-based and reflect the necessary business rules affecting health plans and health care providers and the manner in which they operate pursuant to standards issued under Health Insurance Portability and Accountability Act of 1996. ‘‘(2) OPERATING RULES DEVELOPMENT.—In adopting oper- ating rules under this subsection, the Secretary shall consider recommendations for operating rules developed by a qualified nonprofit entity that meets the following requirements: