Operating Rules to Support Claim Status Transactions

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Adoption Level	Federally required	Cost	Test Tool Availability
Operating Rules	CAQH, Committee on Operating Rules for Information Exchange Claim Status Operating Rules	Final	Production		Yes	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 the standard transactions. They include 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. In 2012, HHS adopted operating rules for claim status, and incorporated the Phase I and II rules by reference in 162.920 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 Claim Status 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 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. Testing between covered entities is always encouraged. Certification for operating rules is voluntary and not currently required by federal regulation. CAQH CORE maintains free implementation tools on its website to support operating rule implementation. Additionally, CAQH CORE offers educational webinars which are archived on its website.

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 the standard transactions. They include 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.
In 2012, HHS adopted operating rules for claim status, and incorporated the Phase I and II rules by reference in 162.920

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 Claim Status 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
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. Testing between covered entities is always encouraged. Certification for operating rules is voluntary and not currently required by federal regulation.
CAQH CORE maintains free implementation tools on its website to support operating rule implementation. Additionally, CAQH CORE offers educational webinars which are archived on its website.

Comment

Submitted by jporras on 2020-11-01

CAQH CORE Comments to ONC ISA - Phase II

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 to Support Eligibility and Claim Status Transactions (Phase II) -- Claim Status Operating Rules

ISA Comments from CAQH CORE 11.1.20 FINAL_0.pdf