Covered Entities: The Role of Electronic Health Clearinghouses

1
Covered Entities The Role of Electronic Health
Clearinghouses
Eligibility Claims Claim Status Remittance
Advice COB Referrals Enrollment Attachments

• Ben Steffen
• Maryland Health Care Commission

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Covered Entities

• Allowed to hold personal health information (PHI)
  for patient care, billing, health care operations
• Providers
• Payers
• Electronic Health Clearinghouses (Electronic
  Health Networks)
• S B 371, Payers use only accredited/certified
  networks

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Clearinghouses Defined

• Health care clearinghouse process health care
  information in non-standard formats and transmit
  in standard formation or receives information in
  a standard format and transmits in a non-standard
  format (HIPAA)
• Maryland Law Entity that sends and receives
  electronic health care transactions COMAR
  10.25.09

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Why Do Clearinghouses Exist?

• Transmitting data is complex
• Over 600 proprietary transmission formats
  nationwide
• Reduces the investment for small businesses,
• 89 of practices are small
• Offer value added services
• EHNs offer additional services or entities of
  larger Health IT firms
• Electronic transactions are the loss leader in a
  battle for medical professions desktops

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Electronic Transactions Submission ...
Payers
Practitioners
Clearinghouses (EHNs)
Standard Format claims
Non standard claims
Standard Format claims
Standard Format claims
Non standard claims

Standard Format claims
Non standard claims
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Types of Clearinghouses

• Electronic Health Networks ?
• Value-Added Networks ?
• Billing Agents
• Repricing Companies
• Community Health Networks

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Clearinghouses Operating In Maryland

• Private networks Internet-Based
• MHIN, EDS ? Healtheon/WebMD ?
• McKesson/HBOC ? PayerPath.Com ?
• Envoy/POS ? RealMed ?
• Per Se Systems ? PassportHealth
• NDC (CIS Technologies) ? ClaimsNet.Com
• ProxyMed ?
• Affiliated Network Services (Dental) ?

?Certified or In Candidacy Status with MHCC