If a payor does not comply with the Transaction and Code Set standards for all eight Transactions by October 2003, what is their penalty?
The penalty for non-compliance with transactions and code sets is $100 per occurrence up to a maximum of $25,000 per standard per year. What most people get confused about is that the maximum is per standard, so that when you calculate how many transaction standards there are to possibly not comply with, the number can add up! Plus, the payers have a greater burden in that they must be ready to comply with all the transaction and code set standards, regardless of whether they are currently performing them electronically or via paper. The Final Rule explains the penalty to be imposed “per violation on any person who fails to comply with a standard” and puts a cap on the amount imposed on any one person per year to be $25,000. Since a provider usually files more than one claim at a time, it would be easy to accumulate many violations with one single transmission. For instance, if a provider sends a batch of claims electronically directly to a payer but does not use the 837 format, the pe
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