- Operating rules for HIPAA standard transactions were added as a requirement of the Patient Protection and Affordable Care Act of 2010, under section 1104, Administrative Simplification.
- Operating rules are intended to support and enhance the use of the standard transactions. They may include certain requirements to help implement the transaction in a more uniform way between health plans and providers, and to ensure a more complete set of information in the response.
- In 2012 HHS adopted CORE Operating Rules for Eligibility and Benefits, which were incorporated by reference at §162.920.
- Prior versions of the adopted operating rules for Eligibility and Benefits are available on the CAQH CORE Mandated Operating Rules website and are incorporated by reference at § 162.920.
- In 2022, The CAQH CORE Operating Rules for Eligibility & Benefits were updated to align with current industry business requirements to better support complex benefit design, telehealth, and support for the implementation of value-based payment initiatives.
- These updates also support the identification of prior authorization requirements for services queried during eligibility verifications in real-time, at the point of care.
- Updated and new CORE Operating Rules for Eligibility & Benefits were recommended for Federal adoption by the National Committee of Vital Health and Statistics (NCVHS) to the Department of Health and Human Services (HHS) in June 2023. Covered entities may refer to the Unified Agenda to determine when these updates will be included in an HHS regulation. A regulation will provide an implementation date.
- Testing, or certification with the operating rules is voluntary and available through CORE. CORE maintains free tools to support operating rule implementation. Additionally, CORE offers educational webinars on its website.