Commission Releases Proposed Regulations for e-billing

In June, the Commission released a set of preliminary regulations for E-Billing with the aim of having a final rule in place this year, with an implementation date of January 1, 2019. The Commission had a working session in August and received comments from interested parties. On September 18, 2018, the Commission issued its proposed final E-Billing regulations, along with a Companion Guide.   The most noticeable change the Commission made was to move the implementation date back six months to July 1, 2019. All non-exempt providers and payers will be expected to be ready to send and receive bills and payment electronically by that date.

In addition, the Commission expanded the definitions to clarify and broaden the exemption to these regulations for small providers, and to create an exemption for small payers. The Commission also clarified the regulations for electronic payments and to make the regulations consistent with the Commission’s “prompt-pay” statute (Va. Code §65.2-605.1).

The original proposed regulations were applicable to every insurer, self-insured, or Group Self-Insurance Association (“GSIA”) doing business in Virginia with no exemptions. The final rule establishes an exemption for payers who processed fewer than 250 medical bills for workers’ compensation treatment services or products in the previous calendar year.

In the preliminary regulations, health care providers were exempt from the regulations if they had 10 or fewer employees and who also provided workers’ compensation treatment accounting for less than 10% of their business. The proposed final rule changes the exemption to cover providers with 10 or fewer full time employees, and for providers who submitted fewer than 250 medical bills for workers’ compensation treatment, services or products in the previous calendar year.

Acceptance of a medical bill does not constitute written notice of injury pursuant to §65.2-600 and §65.2-900, but acceptance of an electronic medical bill, complete or incomplete, does begin the time by which a payer will be required to accept or deny liability for any alleged claim related to the medical treatment pursuant to §65.2-605.1.

The bulk of the regulations set forth the form in which a bill needs to be sent and what codes need to be used. The codes used are uniform codes: HCPCS / CPT-4, CDT-4 for dental, DRG (Diagnosis Related Group), ICD – 10, and NDC codes.

To be “complete,” a bill must:

  • Be in correct format;
  • Be transmitted by accepted electronic format;
  • Include in legible text all supporting documentation for the bill; and
  • Identify the employee, employer/insurer/TPA, provider, and the specific medical services provided.

The regulations provide several new procedures and form notifications for a payer receiving an E-Billing communication, and a time frame in which notices and payment must be sent:

INTERCHANGE ACKNOWLEDGEMENT – Acknowledges that some communication was received from the payer. [16 VA 30-16-50 (D)(1)]

IMPLEMENTATION ACKNOWLEDGEMENT – Acknowledges to the payer that the entire file was, or was not, received. [One business day to send implementation acknowledgement] [16 VA 30-16-50 (D)(2) and (D)(4)]

HEALTH CARE CLAIM ACKNOWLEDGMENT – Acknowledgement of either a complete accurate transmission, or a rejection because of technical noncompliance. [Two business days to send health care claim acknowledgement] [16 VA 30-16-50 (D)(3) and (D)(5)] The regulation notes that acknowledgement of a full and properly formatted submission is not the same as accepting liability to pay the bill. [16 VA 30-16-50 (D)(6)]

ACCEPTANCE OR REJECTION OF RESPONSIBILITY TO PAY – The regulations were amended to expressly acknowledge that the time frame for payment is still governed by §65.2-605.1 (45 days to declare that information is needed, 60 days to deny or pay).

PAYMENT – Now required to be made by electronic deposit unless the payer and the provider agree to handle payment otherwise. Payment is still due within 60 business days, after which judgment interest applies, and payment of the interest is due at the time the bill is paid. The regulation also requires a notification, called an electronic remittance advice (“ERA”), which is similar to a health insurance Explanation of Benefits, and which must be sent before five business days of the date the provider is expected to receive payment. ERAs are also required where the bill is rejected – due within five business days of rejection. [16 VAC 30-16-50 (F)]

COMMUNICATIONS – Particularly regarding incomplete submissions – the regulations set forth that the payer is required to be specific and detailed as to what information is needed to process an incomplete submission, and the regulations implicitly require payers to fill in gaps in a submission where information is already available to them. For example, medical records submitted pursuant to Rule 4.2 are considered part of the submission of the associated bills. Communications with providers are expected to be by telephone or electronic communication and should be thoroughly documented. [16 VAC 30-16-60 and 16 VAC 30-16-70]

To read the text of the proposed final regulations on the Commission’s website, click here.

To download the Electronic Billing and Payment Companion Guide, click here.

Posted In: E-Blast