Operating Rules

Operating rules, as defined in the Patient Protection and Affordable Care Act of 2010 (ACA), are “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications ...”

The Administrative Simplification provisions of the ACA require the Department of Health and Human Services (HHS) to adopt operating rules for the HIPAA named transactions as well as for health care electronic funds transfer (EFT).

CAQH® Committee on Operating Rules for Information Exchange (CORE®)

CAQH® CORE® is an industry-wide stakeholder collaboration committed to the development and adoption of national operating rules for administrative transactions.

The Department of Health and Human Services (HHS) designated CAQH® CORE® as the author of national operating rules for the HIPAA-covered administrative transactions.

Regulations

The U.S. Department of Health and Human Services issued regulations which adopted the CAQH® CORE® Operating Rules, with the exception of acknowledgment provisions, for the following transactions:

  • Eligibility & Benefits -- X12/005010X279A1 Eligibility Benefit Inquiry and Response (270/271).
  • Claim Status – X12/005010X212 Health Care Claim Status Request and Response (276/277).
  • Payment & Remittance – X12/005010X221A1 Health Care Claim Payment Advice (835) and EFT (ACH Electronic Funds Transfer). 

See the Federally Mandated page for additional details

Voluntary Certification

CAQH® CORE® also offers voluntary certification for each set of operating rules approved by its Board and Membership. 

Rule Restructuring

In 2020, CAQH® CORE® restructured its operating rules from a phased-based approach to a transaction-based approach.

The original structure of phase-based rules was:

  • Phase I: Eligibility and Benefits
  • Phase II: Eligibility and Benefits enhancements and Claim Status
  • Phase III: EFT/ERA
  • Phase IV: Claims and Encounters, Benefit Enrollment, Premium Payment, Prior Authorization
  • Phase V: Prior Authorization enhancements

The new structure organizes rules by administrative transaction (such as Eligibility & Benefits) or rule focus (such as Patient Attribution).  For more information, click the plus sign on the right navigation frame of this page and select the topic you wish to view. 

See also https://www.caqh.org/core/new-operating-rule-structure. 

Nacha (National Automated Clearing House Association)

Nacha governs the ACH Network, the payment system driving direct deposits and payments in the financial industry.  Nacha maintains standards and operating rules for financial transactions traveling over the Automated Clearing House (ACH) Network, including healthcare electronic funds transfer (EFT) transactions.

NCPDP® (National Council for Prescription Drugs Programs, Inc.)

NCPDP® maintains operating rules for the retail pharmacy transactions within their NCPDP Telecommunication Standard.  

X12 manages the exclusive copyright to all X12 standards, publications, and products; see https://x12.org/products/ip-use for details. The X12 TR3 that details the full requirements for this transaction can be licensed at https://x12.org/licensing. 

CORE®, the CORE-certification/Endorser Seals and logo are registered trademarks of CAQH®, copyright 2021, Council for Affordable Quality Healthcare®.

NCPDP® is a registered trademark of the National Council for Prescription Drugs Programs, Inc.