- 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 may 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 the process of electronic funds transfer transactions, the operating rules require a standard enrollment data set for all health plans to use with providers.
- In 2020 CAQH CORE updated its phase-based operating rule structure to align with the business processes supported by the rules. Prior versions of the CAQH CORE ERA/EFT Operating Rules are incorporated by reference in § 162.920 and available on the CAQH CORE Mandated Operating Rules website along with a crosswalk to the new operating rule naming and versioning conventions
- 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. The checklist is available on the website.
- CAQH CORE maintains 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