- Operating rules were included 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 adopted standard transactions. They may include certain requirements to help implement the transaction in a more uniform way between health plans, ensure a more complete set of information, and more consistent use of the adopted standards.
- HHS has adopted operating rules for Eligibility and Benefits and Claim Status (2011), and Electronic Funds Transfer and Electronic Remittance Advice (2013).
- As of 2022, HHS has not yet adopted Operating Rules for other HIPAA transaction standards, including Enrollment and Disenrollment, Premium Billing, Health Care Claims, and Prior Authorization.
- CAQH CORE has developed Operating Rules for Enrollment and Disenrollment which are available for voluntary use by covered entities.
- Testing or certification with operating rules is voluntary and available through a vendor contracted to CAQH CORE. There is a fee for certification, however, CAQH CORE maintains free tools to support operating rule implementation. Additionally, CAQH CORE offers educational webinars which are archived on its website.
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Submitted by mphillips@caqh.org on 2022-09-27
CAQH CORE Operating Rules for Benefit Enrollment Updates
Updates to the CAQH CORE Operating Rules for Benefit Enrollment are on pages 13-14 in the attached document. Proposed changes are primarily non-substantive in nature and address consistency, conciseness, and grammar and syntax. Changes are highlighted in gray with proposed deletions shown as strikethrough text.CAQH CORE ISA Letter 2022_5.pdf