- Operating rules were adopted 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 additional 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. For example, rather than just “yes or no” for eligibility information, the operating rule requires health plans to return patient eligibility and financial responsibility for a list of service types such as emergency care, inpatient hospitalization, and dental and vision services. For the process of electronic funds transfer transactions, the operating rules require a standard enrollment data set for all health plans to use with providers.
- Operating rules include other business rules to support the eligibility transaction as it moves between the provider and the health plan, such as the format of the health plan’s companion guide (see CORE Rule 152), as well as response time for real time and batch transactions (see CORE Rules 155 and 156).
- 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. This is where the convergence of administrative and clinical systems will take place with respect to patient benefit information in the electronic health record.
- These operating rules include CAQH CORE policies for voluntary testing and certification, which are not mandatory. The other rules support the EFT and ERA through a range of requirements, from the companion guide template, to the uniform use of combinations for certain Claim and Remark Codes (CARCs and RARCs), to certain standard data elements for enrolling providers electronically for EFT or ERA transactions.
- Phase III Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) for Payments and Reconciliation include:
- (1) Phase III CORE 350: Healthcare Claim Payment/Advice (835) Infrastructure Rule (Incorporated by reference in §162.920)
- (2) Phase III CORE 360: Uniform Use of CARCs and RARCs (835) Rule (Incorporated by reference in §162.920)
- (3) Phase III CORE 370: EFT and ERA Reassociation (CCD+/835) Rule (Incorporated by reference in §162.920)
- (4) Phase III CORE 380: EFT Enrollment Data Rule (Incorporated by reference in §162.920)
- (5) Phase III CORE 382: ERA Enrollment Data Rule (Incorporated by reference in §162.920)
- 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