- Operating rules were adopted as a requirement of the Patient Protection and Affordable Care Act of 2010, under section 1104, Administrative Simplification. Note: Phase IV operating rules have not yet been recommended for adoption by NCVHS but are available for voluntary use.
- Operating rules are intended to support and enhance the use of the standard transactions. They include additional requirements to help implement the transaction in a more uniform way across health plans, and ensure a more complete set of information in the response.
- Operating rules are developed through workgroups which are consensus driven, based on the members who participate. Greater participation from more diverse members will result in more robust content and utility to enable to the rules to support the transactions and serve the users effectively.
- The Phase IV CAQH CORE Operating Rules, available for use on a voluntary basis as of September 2015, include:
- Phase IV CAQH CORE 450: Health Care Claim (837) Infrastructure Rule
- Phase IV CAQH CORE 452: Health Care Services Review – Request for Review and Response (278) Infrastructure Rule
- Phase IV CAQH CORE 454: Benefit Enrollment and Maintenance (834) Infrastructure Rule
- Phase IV CAQH CORE 456: Payroll Deducted and Other Group Premium Payment for Insurance Products (820) Infrastructure Rule
- Phase IV CAQH CORE 470: Connectivity Rule
- Testing, or certification with the operating rules is voluntary and available through a vendor contracted to the authoring entity. The checklist is available on the website.
- CAQH CORE maintains a host of free implementation tools to support operating rule adoption on its website. Additionally, CAQH CORE offers regular educational webinars which are archived on its website to drive greater industry awareness of the value of operating rules in collaboration with leading healthcare organizations