Regs on EOB formatting?

[Guest bayarea1]

Can anyone give me direction toward finding ERISA/HIPAA or like regs on the information that is required to be reported on an explaination of benefits (EOB)?

[KIP KRAUS]

I have never seen any ERISA or HIPAA regulations that address EOB content. The state insurance commissions may regulate this, but I have never come across any such regs. by a state. If the insurer has the option of what goes on EOBs then I would contact them for guidance.

Most EOBs I’ve seen are lacking in detail as to the exact reasons for denials, but if the claim is paid then they usually give enough detail as to how it was paid.

I'm not sure that ERISA or HIPAA addresses EOBs.

[Jbentz]

My expertise is in the Privacy Rule, but I believe what you may be looking for is under the Transactions and Code Set piece of HIPAA.

I copied this from the the HIPAAdvisory.com website:

HIPAA defines EDI healthcare transactions as:

Health claims or similar encounter information

Health care payment & remittance advice

Coordination of Benefits

Health claim status

Enrollment & dis-enrollment in a health plan

Eligibility for a health plan

Health plan premium payments

Referral certification & authorization

First report of injury (will not be included in Final Rule)

Health claims attachments (will not be included in Final Rule)

I believe you may be under the second one "Remittance Advice" and the third one "COB", depending if you are using an electronic format. I know i have heard a lot of talk about EOB's and the codes used. You can see the regs at www.hipaadvisory.com. This is a great website, lots of information about all the HIPAA regs.

Hope this helps!

[jeanine]

Under the new claims and appeals regs that apply to all ERISA plans, any denial of a claim for benefits must include:

-specific reason for denial of adverse benefit

-reference to specific plan provision upon which denial is based

-description of additional information needed to perfect claim

-if relied upon, reference to internal rule or guideline used and how to request a copy of such

-if medical necessity/experimental treatment, must explan scientific or clinical judgment and apply it to the claimant's condition

-notice of right to request review and explanation of review process

Is this what you are asking about? These regs are effective for claims for plans renewing on or after July 1, 2002 but no later than January 1, 2003. If you use the EOB as a notice of adverse benefit determination (as we do) you must find a way to get all of this on to the EOB, or use a different mechanism to advise claimants of your decision

[Guest bayarea1]

Thank you everyone for your excellent responses! They were all very helpful and steered me in the right direction.