Administrative Simplification: Eligibility and claim status


The Administrative Simplification provision under Section 1104 of the Patient Protection and Affordable Care Act (the Act) intends to improve the standards for electronic transactions mandated by the Health Insurance Portability and Accountability Act (HIPAA). The intent of this provision is to reduce administrative costs by adopting a set of operating rules for each transaction and to create as much uniformity in implementing electronic standards as possible.

Video: Administrative Simplification and the Affordable Care Act

Paying for a doctor visit or seeing a specialist often involves complex paperwork. This provision has the potential to simplify our experience with the health care system. View video

The rules for Administrative Simplification govern the compliance by covered entities – health benefit plans, health care clearinghouses, and certain health care providers.

To date, the Department of Health and Human Services (HHS) released two interim final rules (IFR) that govern compliance for eligibility and claim status and the second for electronic funds transfer (EFT) and electronic remittance advice (ERA). A final rule was issued on health plan and national provider identifiers.

Health Plan Identifier and National Provider Identifier

On Aug. 24, 2012, a final rule was issued that (1) adopts a 10-digit health plan identifier (HPID) for health plan entities to use in transactions with other covered entities, and (2) requires certain individual health care providers, who previously were not required to do so, obtain and disclose a national provider identifier (NPI) in 2013. At this time, the use of an HPID would only be required for electronic transactions.

The effective date to comply is Nov. 5, 2014, and small health plans Nov. 5, 2015.


The Aug. 24 final rule delays the implementation date for ICD-10 from Oct. 1, 2013, to Oct. 1, 2014, based on concerns from providers about their ability to meet the 2013 deadline. HHS believes the delay would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all industry segments.

While UnitedHealthcare was prepared to launch ICD-10 by the original Oct. 1, 2013 date, the proposed 12-month delay allows more time to assist, educate and train providers on the new coding requirement.

Electronic Funds Transfer and Remittance Advice Transactions

On Jan. 5, 2012, HHS released an IFR addressing the standards for EFT and ERA transactions that a health plan must comply with to transmit payments to providers via EFT.

Today, with few exceptions, the electronic remittance advice and the health care payment/processing information are sent in different electronic formats through different networks, contain different data that have different business uses, and are often received by the health care provider at different times. The two transmissions must be "reassociated" or matched back together by the provider.

The HHS believes this issue can be alleviated by requiring that a single electronic file format be used by all health plans that transmit health care EFT to their financial institutions.

UnitedHealthcare is compliant under the requirements outlined in the IFR and continues to encourage providers to sign up for EFT and ERA which they can request

Eligibility and Claim Status

On July 8, 2011, the IFR outlined operating rules covering two electronic health care transactions:

  • Eligibility – verifying if a patient has sufficient coverage (e.g., benefit coverage, copays, base deductible and remaining deductible); and
  • Claim Status – the stage of a health care claim (pending, allowed, settled, denied, etc.) after it's submitted to a health insurance company.

UnitedHealth Group completed the CORE Phase I and II testing process that certifies that UnitedHealth Group can deliver more efficient and predictable patient-eligibility and claims-verification information to physicians, hospitals, physician offices and other care providers. UnitedHealth Group is the first health care organization to complete certification using the updated 5010 platform.


Jan. 1, 2013 Eligibility and claim status operating rules compliance date.
May 6, 2013 National Provider Identifier compliance date.
Oct. 1, 2014 ICD-10 new compliance date.
Jan. 1, 2014 Electronic funds transfer and electronic remittance advice compliance date.
Nov. 5, 2014 Health Plan Identifier compliance date. For small health plans, the date is Nov. 5, 2015.

These rules are part of a series of administrative simplification rules expected over the next several years required by the Act. Below are future regulations and their proposed effective dates for compliance:

  • Requirements that health benefit plans certify compliance with all HIPAA standards and operating rules, and phased in beginning Jan. 1, 2014
  • Operating rules for claims and encounters, enrollment/disenrollment, premium payments, referral certification/authorization, and claim attachments, effective Jan. 1, 2016

For More Information

  • Overview: Administrative Simplification/HIPAA 5010/ICD-10 flier (PDF)
  • News Release: UnitedHealth Group is First to Achieve CAQH CORE Certification – April 12, 2011 (PDF)