CAQH® CORE Operating Rules for Premium Payments

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Adoption Level	Federally required	Cost	Test Tool Availability
Operating Rules	CAQH® CORE Operating Rules for Premium Payments	Final	Production		No	Free	Yes^$

Limitations, Dependencies, and Preconditions for Consideration	Applicable Security Patterns for Consideration
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 HIPAA standard transactions. They may include certain requirements to help implement the transaction in a more uniform way between health plans and providers, to 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 had not adopted Operating Rules for other HIPAA standards, including Benefits Enrollment and Disenrollment, Premium Billing, Health Care Claims, and Prior Authorization. CAQH CORE has developed Operating Rules for Premium Payments 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.	Feedback requested.

Limitations, Dependencies, and Preconditions for Consideration

Applicable Security Patterns for Consideration

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 HIPAA standard transactions. They may include certain requirements to help implement the transaction in a more uniform way between health plans and providers, to 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 had not adopted Operating Rules for other HIPAA standards, including Benefits Enrollment and Disenrollment, Premium Billing, Health Care Claims, and Prior Authorization.
CAQH CORE has developed Operating Rules for Premium Payments 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.

Feedback requested.

Comment

Submitted by mphillips@caqh.org on 2022-09-27

CAQH CORE Operating Rules for Premium Payment Updates

Updates to the CAQH CORE Operating Rules for Premium Payment are on pages 14-15 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_6.pdf

Submitted by doodles531 on 2020-12-13

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CAQH® CORE Operating Rules for Premium Payments

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CAQH CORE Operating Rules for Premium Payment Updates

updated weblink

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