Clearinghouse Roles in Testing

q Clearinghouses should assist their customers with compliance validation for HIPAA standard transactions that are either routed or generated by their system during direct trading partner testing.

q Submitters and receivers, whether they are payers or providers, have the majority of responsibility for HIPAA compliance. They may use an agent such as a clearinghouse to help achieve HIPAA compliance. The expectation for testing and validation for HIPAA compliance needs to be established between the submitter and receiver and their respective clearinghouses as applicable if “translation” services are being performed on behalf of either organization.

q In the case of the transmission of a non-compliant transaction via a clearinghouse, submitters and receivers are ultimately responsible for the production of HIPAA compliant data content. Clearinghouses, acting on behalf of the submitter or receiver, can and should validate the compliance of data content when reformatting a non-standard format into a HIPAA compliant format.

q Submitters and receivers should work with their clearinghouses to set the proper expectations for testing of HIPAA compliant transactions with their trading partners. Some trading partners adhere to more rigid or strict testing requirements than others; therefore, clearinghouses should be prepared to perform a variety of testing based on the respective trading partners’ policies and procedures.

q It is important to note and communicate any known dependencies which may be introduced due to clearinghouse limitations which deviate from the trading partner’s own capability or compliance e.g. transaction size limitations, identifier use.

q Recognizing that multiple clearinghouses may be involved in the exchange between a submitter and receiver necessitates increased awareness of what processes (e.g. translation, element defaults etc.) are being applied against a transaction in order to determine compliance.

Clearinghouse definition per 45CFR Part 160 Subpart A – General Provisions 160.103 Definitions

“Health care clearinghouse means a public or private entity that does either of the following (Entities, including but not limited to, billing services, repricing companies, community health management information systems or community health information systems, and ``value-added'' networks and switches are health care clearinghouses for purposes of this subchapter if they perform these functions:
 
(1) Processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction.
 
(2) Receives a standard transaction from another entity and processes or facilitates the processing of information into nonstandard format or nonstandard data content for a receiving entity.”
 
Federal Register August 17, 2000