Operating Rules for Health Care Claims

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Adoption Level	Federally required	Cost	Test Tool Availability
Operating Rules	CAQH® CORE Operating Rules for Health Care Claims	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 standard transactions adopted under HIPAA. They may include certain 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. HHS has adopted operating rules for Eligibility and Benefits and Claim Status (2011), and Electronic Funds Transfer and Electronic Remittance Advice (2013). HHS has not adopted Operating Rules for other HIPAA transaction standards, including Health Care Claims, Prior Authorization, Premium Billing, and Enrollment/Disenrollment. The CAQH CORE Health Care Claims Operating Rules are available for voluntary use by covered entities. In 2022, CAQH CORE updated this voluntary rule set to support the electronic exchange of attachments and medical information. 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 standard transactions adopted under HIPAA. They may include certain 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.
HHS has adopted operating rules for Eligibility and Benefits and Claim Status (2011), and Electronic Funds Transfer and Electronic Remittance Advice (2013).
HHS has not adopted Operating Rules for other HIPAA transaction standards, including Health Care Claims, Prior Authorization, Premium Billing, and Enrollment/Disenrollment.
The CAQH CORE Health Care Claims Operating Rules are available for voluntary use by covered entities. In 2022, CAQH CORE updated this voluntary rule set to support the electronic exchange of attachments and medical information.
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 Health Care Claims Updates

Updates to the CAQH CORE Operating Rules for Health Care Claims are on pages 11-13 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_4.pdf

Submitted by pwilson@ncpdp.org on 2021-09-29

NCPDP Comments

Add the following:

Type-Implementation Specification Standard Implementation/Specification- NCPDP Telecommunication Standard, Implementation Guide, Version D.0 Standards Process Maturity – Final Implementation Maturity- Production Adoption Level – 5 Federally Required – No Cost – $ Test Tool Availability – No

NCPDP operating rules are in the NCPDP Telecommunication Standard, Implementation Guide, Version D.0

Submitted by doodles531 on 2020-12-13

updated weblink

Submitted by jporras on 2020-11-01

CAQH CORE Comments to ONC ISA - Phase IV

Aligning ISA with New Operating Rule Structure: In Spring 2020, CAQH CORE restructured its operating rules from phase-based rule sets to rule sets based on the business processes supported by the rules. No substantive changes were made to existing rule requirements. As a result of the restructuring, CAQH CORE recommends updates to the following sections of the ISA: Operating Rules for Claims, Enrollment, and Premium Payment (Phase IV) -- Healthcare Claims Operating Rules, Benefit Enrollment Operating Rules, Premium Payment Operating Rules

ISA Comments from CAQH CORE 11.1.20 FINAL_3.pdf

Submitted by jporras on 2019-09-23

CAQH CORE Comments to ONC ISA 2020 Ref Edition - Phases IV & V

2. Implementation Maturity and Adoption Level for Operating Rules for Claims, Enrollment, and Premium Payments (Phase IV) CAQH CORE recommends changing the Implementation Maturity for the Phase IV Operating Rules from “Pilot” to “Production”. Entities are actively implementing this rule set and achieving Phase IV CORE Certification. Additionally, we recommend updating the Adoption Level to 1 out of 5. 3. Addition of the Phase V Operating Rules for Prior Authorization CAQH CORE is pleased to announce the release of the final Phase V Operating Rules for the prior authorization transaction and recommends ONC expand the ISA content in Section IV: Administrative Standards and Implementation Specifications - Operating Rules to Support Administrative Transactions to include this rule set. The Phase V CAQH CORE Operating Rules, approved in May 2019, include: • Phase V CAQH CORE Prior Authorization (278) Request / Response Data Content Rule v5.0.0 • Phase V CAQH CORE Prior Authorization Web Portal Rule v5.0.0 The Phase V CAQH CORE Operating Rules focus on standardizing components of the prior authorization process, closing gaps in electronic data exchange to move the industry towards a more fully automated adjudication of a request. To develop the Phase V Operating Rules, CAQH CORE conducted an environmental scan of over 100 entities, participated in industry meetings and convened multi-stakeholder groups to agree on opportunities for operating rule development and refine rule requirements. CAQH CORE recommends the following additional content for the Phase V Rules: • Type: Operating Rules • Standard / Implementation Specification: CAQH CORE Phase V Operating Rule Set • Standards Process Maturity: Final • Implementation Maturity: Pilot • Adoption Level: 1 out of 5 • Federally Required: No • Cost: Free • Test Tool Availability: Yes The Limitations, Dependencies, and Preconditions for Consideration section can mirror that for the other operating rule sets with the exception of the fourth bullet which should read: • The Phase V CAQH CORE Operating Rules, available for use on a voluntary basis as of May 2019, include: o Phase V CAQH CORE Prior Authorization (278) Request / Response Data Content Rule v5.0.0 o Phase V CAQH CORE Prior Authorization Web Portal Rule v5.0.0

CAQH CORE Comment Letter to ONC ISA_2.pdf

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