Announcement Detail

White Paper: No Surprises Act Good Faith Estimate / Advanced EOB Standards-based Approach


Compelling Standards-based Solution to Support Predetermination of Benefit / Estimation Workflows as Required by the No Surprises Act

For Immediate Release

Washington DC (October 19, 2021) – Today Cooperative Exchange, The National Clearinghouse Association, announced the publication of a white paper titled No Surprises Act Good Faith Estimate /Advanced EOB Standards‐based Approach White Paper. The No Surprises Act (NSA), signed into law as part of the Consolidated Appropriations Act of 2021, was an important step toward protecting consumers from surprise medical bills and providing transparency regarding health care costs.

Section 111 of the Act calls for an Advanced Explanation of Benefit (AEOB) of anticipated services for insured beneficiaries. The Cooperative Exchange concurs that the Good Faith Estimate (GFE) and AEOB requirements, once implemented appropriately, will arm insured patients with the information they need to make informed decisions regarding their health care. Cooperative Exchange member constituents collaborated to produce the white paper which provides a rational justification to pursue a standards-based approach primarily leveraging existing, broadly adopted, and mature X12 administrative transactions and established infrastructure while minimizing administrative burden for all stakeholders. 

The same industry standards and infrastructure in place today supporting BILLIONS of patient/plan centric healthcare transactions can be leveraged to estimate services/items
in the same manner as billing for services/items to maximize operational and fiscal investments already made by the industry and minimize burden for all stakeholders.

“We appreciate the opportunity to share the amazing work of our committee members and trust this paper presents a compelling solution for leveraging existing X12 published standards to support Predetermination of Benefit / Estimation workflows,” said Crystal Ewing, Board Chair, Cooperative Exchange.

Predetermination/Estimation workflow using X12 standards has been in production supporting the Dental industry since October 2003.

The Cooperative Exchange is committed to support the successful development and implementation of the No Surprises Act regulations and related guidance and educational programs.

About the Cooperative Exchange

The Cooperative Exchange is a nationally recognized association representing the healthcare clearinghouse industry in the United States. Our 23 clearinghouse member companies represent over 90% of the nation’s clearinghouse organizations and process over 6 billion healthcare claims, reflecting over 2 trillion dollars in billed services annually. Our association members enable nationwide connectivity between over 1 million provider organizations, more than 7,000 payers, and 1,000 Health Information Technology (HIT) vendors. The Cooperative Exchange truly represents the U.S. healthcare electronic data interchange (EDI) interstate highway system enabling connectivity across all lines of healthcare eCommerce in the United States.

Cooperative Exchange member clearinghouses support both administrative and clinical industry interoperability by:

  • Managing tens of thousands of entities and connection points
  • Exchanging complex administrative and clinical data content in a secure manner
  • Supporting both real-time and batch transaction standards
  • Enabling interoperability by normalizing disparate data to industry standards
  • Delivering flexible solutions to accommodate varying levels of stakeholder readiness (low tech to high tech)
  • Providing strong representation and participation across all national healthcare standard and advocacy organizations with many of our members holding leadership positions

Therefore, we strongly advocate for EDI standardization and administrative simplification within the healthcare industry.