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).
Operating Rule Authoring Entities
CAQH Committee on Operating Rules for Information Exchange (CORE®)
CAQH CORE is an industry-wide collaboration of stakeholders in the health care industry committed to the development and adoption of national voluntary operating rules for electronic business transactions.
NACHA-The Electronic Payments Association
NACHA maintains standards and operating rules for financial transactions traveling over the Automated Clearing House (ACH) Network, including healthcare electronic funds transfer (EFT) transactions.
National Council for Prescription Drug Programs (NCPDP)
NCPDP maintains operating rules for the retail pharmacy transactions within their Telecommunication Standard. HHS determined that these were sufficient and did not include retail pharmacy in the Eligibility and Claim Status Operating Rules regulation.
Eligibility and Claim Status Regulation
On July 8, 2011 HHS published Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions; Interim Final Rule which requires non-retail pharmacy HIPAA covered entities to conform to a subset of the CAQH CORE Phase I and II Operating Rules, which address the following ASC X12N transactions:
- Health Care Eligibility Benefit Inquiry and Response (270/271)
- Health Care Claim Status Request and Response (276/277)
The Interim Final Rule established a compliance date of January 1, 2013, with an enforcement discretionary period ending March 31, 2013. The discretionary enforcement period did not change the compliance date of the regulation – the enforcement delay simply stated that CMS would not enforce compliance.
All Change Healthcare products and services comply with the Eligibility and Claim Status Operating Rules IFC.
View More on the Phase I and II Operating Rules
EFT / ERA Regulation
On August 10, 2012 HHS published The Administrative Simplification: Adoption of Operating Rules for Health Care Electronic Funds Transfers (EFT) and Remittance Advice Transactions; Final Rule
which requires HIPAA covered entities to conform to a subset of the CAQH CORE Phase III Operating Rules. The Phase III Operating Rules address the following transactions:
- ASC X12N Health Care Claim Payment/Advice (835)
- Automated Clearing House (ACH) Cash Concentration/Disbursement plus Addenda (CCD+)
The Final Rule established a compliance date of January 1, 2014.
All Change Healthcare products and services comply with the ERA and EFT Operating Rules Final Rule.
View More on the Phase III Operating Rules
Claims And Encounters, Benefit Enrollment, Premium Payment, Referrals And Authorizations – Regulation Not Anticipated
CAQH CORE has developed operating rules for the following ASC X12N transactions for their voluntary certification process:
- Health Care Claims: Institutional (835I), Professional (835P), and Dental (837D)
- Health Care Services Review – Request for Review and Response (278)
- Benefit Enrollment and Maintenance (834)
- Payroll Deducted and Other Group Premium Payment for Insurance Products (820)
On July 6, 2016, the National Committee on Vital and Health Statistics (NCVHS), advisory body to the Department of Health and Human Services, recommended that the Phase IV Operating Rules not be adopted under regulatory mandate and instead supported voluntary industry adoption.
Recommendations also included; addressing inconsistencies in authentication and connectivity requirements, regulatory adoption of the acknowledgement standard as HIPAA-mandated, and transaction-specific findings and recommendations.
To see the NCVHS recommendation, go to www.ncvhs.hhs.gov.
Regulatory action on the Phase IV operating rules is not anticipated.