CORE Operating Rules
The Patient Protection and Affordable Care Act (ACA) defines operating rules as, “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.”
Operating rules build on existing standards to make electronic transactions more predictable and consistent, regardless of the technology. Rights and responsibilities of all parties, security, transmission standards and formats, response time standards, liabilities, exception processing, error resolution and more must be clearly defined in order to facilitate successful interoperability. Beyond reducing cost and administrative hassles, operating rules foster trust among all participants.
All CORE rules will build on applicable HIPAA requirements and other related standards.
CORE is focused on creating operating rules and will not develop software solutions, a switch, a database or central repository of administrative information.
Eligibility and Claim Status Operating Rules: Phase I and Phase II (Federally mandated via Final Rule)
EFT & ERA Operating Rules: Phase III (Federally mandated via Final Rule)
DRAFT Claims, Prior Authorization, Benefit Enrollment & Maintenance, & Premium Payment Operating Rules: DRAFT Phase IV (Currently under development)
Other Voluntary Operating Rules: Email CORE@caqh.org for more information or copies.