- Operating rules were included as a requirement of the Patient Protection and Affordable Care Act of 2010 (ACA), under section 1104, Administrative Simplification.
- Operating rules are intended to support and enhance the use of the standard transactions. They include requirements to help implement the transaction in a more uniform way between health plans and providers and ensure a more complete set of information in the response.
- In 2013, HHS adopted the Phase III CAQH CORE Operating Rules for EFT and ERA, which were incorporated by reference at §162.920.
- In 2020, CAQH CORE updated its phase-based operating rule structure to align with the business processes of covered entities, and retired the phase structure. HHS has not yet released new regulations or guidance to adopt the documents or revisions to the operating rules. Prior versions of the CAQH CORE Operating Rules for EFT and ERA adopted operating rules are available on the CAQH CORE Mandated Operating Rules website.
- The ERA/EFT rules support the uniform use of combinations for certain Claim and Remark Codes (CARCs and RARCs), as well as use of certain standard data elements for enrolling providers electronically for EFT or ERA transactions.
- Testing or certification with the operating rules is voluntary and available through a vendor contracted to the authoring entity. 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.