Operating Rules Mandate - EFT and ERA
Coordination with Financial Services Industry | Role of CAQH CORE
Getting Involved with CAQH CORE | Education and Outreach | Implementation Resources | Contacts
Status of Mandated EFT & ERA Operating Rules
On March 23, 2011, NCVHS sent a letter to the Secretary of HHS making a recommendation to name "CAQH CORE in collaboration with NACHA The Electronic Payments Association as the candidate authoring entity for operating rules for all healthcare EFT and ERA transactions..."
On August 1, 2011, CAQH CORE and NACHA jointly submitted a letter to the Co-Chairs of the National Committee on Vital and Health Statistics (NCVHS) Subcommittee on Standards, an advisory body to the Department of Health and Human Services (HHS), to provide an update on progress developing healthcare operating rules for EFT & ERA, including links to rules.
On December 7, 2011, NCVHS sent a letter to Secretary Sebelius, HHS, making a recommendation the Secretary adopt the set of five operating rules submitted to NCVHS by CAQH CORE and NACHA, conditional on the authoring entities making certain revisions to the proposed operating rules. A key condition was that the rules should not require CORE Certification, which they do not.
On August 10, 2012, HHS issued an Interim Final Rule with Comment (IFC) adopting the complete Phase III CAQH CORE EFT & ERA Operating Rules, including the CORE v5010 Master Companion Guide Template, to fulfill the ACA Section 1104 Federal mandate for national EFT & ERA Operating Rules. (NOTE:CAQH CORE requirements pertaining to the use of Acknowledgements are not included for adoption.) CAQH CORE developed a model comment letter for CORE Participating Organizations to submit, the letter can be viewed here.
In April 2013, CMS issued a notice adopting CMS-0028-IFC as a Final Rule. Industry implementation efforts should be well underway for the January 1, 2014 effective date for implementation of the Federally mandated CAQH CORE EFT & ERA Operating Rules. This notice also urged stakeholders to get involved in the CAQH CORE Code Combinations Maintenance Process.
CAQH CORE EFT & ERA Operating Rules
For quick reference, CAQH CORE has developed a brief high-level overview of the CAQH CORE EFT & ERA Operating Rules.
The Complete Set of Phase III CORE EFT & ERA Operating Rules, developed by CORE Participants with industry input, was approved in the final CORE vote in June 2012 as the final step in the CORE Voting Process. To support the CORE Guiding Principles and align with Federal efforts, the CAQH CORE EFT & ERA Operating Rules:
- Do not include references to voluntary CORE Certification (e.g., A CORE-certified entity must )
- Each include a Conformance Requirements section to clarify that CMS will determine conformance with the Federal mandates
- Include appropriate references to the January 2012 Interim Final Rule with Comment (CMS-0024-IFC): Administrative Simplification: Adoption of Standards for Health Care Electronic Funds Transfers (EFTs) and Remittance Advice
Links to the individual rules are available below.
- CAQH CORE 350: Health Care Claim Payment/Advice (835) Infrastructure Rule
- CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule
- CORE-required Code Combinations for CORE-defined Business Scenarios for CAQH CORE Rule 360 v3.0.1 January 2013
- This document aligns with the current published CARC and RARC lists and supersedes v3.0.0. The list was approved by the CAQH CORE Code Combination Task Group in January 2013. Per CMS OESS, this document is immediately recognized under HIPAA given that CAQH CORE Rule 360 requires that adjustments made by the code list authors be addressed by CORE. It has been placed in Excel for ease of use. For a marked up version showing the adjustments between v3.0.0 and v3.0.1 please email CORE@caqh.org.
- To learn more about the CAQH CORE Code Combinations Maintenance Process click HERE. To learn more about the CAQH CORE Code Combinations Emergency Update Process click HERE. A webpage with detailed information specific to CAQH CORE Rule 360 and CAQH CORE Code Combinations Maintenance Process is being developed by CAQH CORE staff and will be available as a resource in Q1 of 2013.
- CAQH CORE 370: EFT & ERA Reassociation (CCD+/835) Rule
- CAQH CORE 380: EFT Enrollment Data Rule
- CAQH CORE 382: ERA Enrollment Data Rule
Per the CORE Rules Development Process, for each CAQH CORE Rule Set, a Voluntary CORE Certification Test Suite is developed specifying how entities can achieve voluntary CORE Certification with the rule set. The Phase III CORE EFT & ERA Operating Rules Voluntary Certification Test Suite was also approved in the final CORE vote in June 2012. Voluntary CORE Certification will be available for the CAQH CORE EFT & ERA Operating Rules by early 2013.
Key Dates for EFT and ERA
The following dates are critical for industry implementation of the Federally mandated CAQH CORE EFT and ERA Operating Rules. Note there are two types of penalties related to compliance with the mandated operating rules.
- January 1, 2014: Effective Date by which HIPAA-covered entities must comply with the Federally mandated CAQH CORE EFT and ERA Operating Rules
- * Penalties for All HIPAA-covered Entities: The HIPAA Administrative Simplification provisions require all HIPAA-covered entities to comply with the Federally mandated requirements by their effective dates (January 1, 2014 for the EFT and ERA operating rules). The penalties to be assessed for non-compliance were formalized in the original HIPAA legislation and updated by the Health Information Technology for Economic and Clinical Health (HITECH) rules in 2009. Due to HITECH, CMS OESS (Office of E-Health Standards and Services) penalties for HIPAA non-compliance have increased, now up to $1.5 million per entity per year.
- December 31, 2013: Certification Date by which health plans must file a statement with HHS certifying that their data and information systems are in compliance with the standards and operating rules including the Federally mandated CAQH CORE EFT and ERA Operating Rules
- According to CMS, regulation detailing the health plan certification process is under development, and they will release details surrounding this process later this year.
- No Later than April 1, 2014: Health Plan Penalty Date by which CMS will begin assessing penalties against health plans that have failed to meet the certification and compliance requirements for standards and operating rules per Section 1104 of the ACA, including the Federally mandated CAQH CORE EFT and ERA Operating Rules
- * Penalties for Health Plan Certification: The ACA requires HHS to assess penalties against health plans that fail to certify compliance; the fee amount equals $1 per covered life until certification is complete (covered life for which the plans data systems are not in compliance and shall be imposed for each day the plan is not in compliance).
View the CAQH CORE timeline of key activities related to Federally mandated operating rules.
View the CMS list of Deadlines and Key Dates for HIPAA Administrative Simplification Compliance.
*NOTE: The CMS OESS is the authority on the HIPAA and ACA Administrative Simplification provisions and requirements for compliance and enforcement. The CMS website provides information on the ACA compliance, certification, and penalties and enforcement process.
Coordination with Financial Services Industry: NACHA's Proposed Enhancement to NACHA Operating Rules Due to Healthcare Use of EFT
The financial services industry maintains its own set of operating rules (NACHA Operating Rules and Guidelines) which govern the ACH Network. The NACHA Operating Rules are separate and distinct from the CAQH CORE Operating Rules and address the use of the electronic funds transfer (EFT) standard. Only financial institutions are formal members of NACHA The Electronic Payments Association and can directly decide on the NACHA Operating Rules content.
CAQH CORE and NACHA have been working in partnership as the healthcare industry moves to adopt the industry-neutral EFT and a set of EFT & ERA healthcare operating rules. In March of 2012, NACHA issued a Request for Comment (RFC) on potential amendments to the NACHA Operating Rules with comments due by April 27th. The purpose of these amendments is to address both enhancements requested by the healthcare industry to improve the delivery of remittance information contained in EFT payments transmitted via the ACH Network, as well as other enhancements identified by the NACHA membership.
CAQH CORE submitted comments to NACHA for its consideration based on feedback from CORE Participants on the RFC. In addition, the CAQH CORE Rules Work Group held a call on May 18th, 2012 on which NACHA staff provided insight and rationale for the proposed enhancements and answered questions on the framework of the ACH Network as it relates to the proposed enhancements. CAQH CORE will continue to follow and report out to the healthcare industry on the NACHA process and ensure healthcare comments are understood.
For more information on the CAQH CORE comments on the NACHA RFC, please email CORE@caqh.org.
Role of CAQH CORE for EFT & ERA
The complete Phase III CAQH CORE EFT & ERA Operating Rules, including the CORE v5010 Master Companion Guide Template are adopted in the August 10, 2012, HHS Interim Final Rule with Comment (IFC) (CMS-0028-IFC). NCVHS recommended to HHS that CAQH CORE and NACHA The Electronic Payments Association, be the authoring entities for the second set of Federally mandated operating rules for the electronic funds transfer (EFT) and electronic remittance advice (ERA) transactions. The CAQH CORE EFT & ERA Operating Rules are fulfilling ACA operating rule requirements for the two transactions.
For more information on the role of CAQH CORE, email CORE@caqh.org.
Getting Involved with CORE for EFT & ERA
The Phase III CAQH CORE EFT & ERA Operating Rules have been adopted by HHS as an Interim Final Rule. However, CAQH CORE continues to welcome participants from all healthcare stakeholder groups to contribute to future operating rule development. There are multiple ways to become involved in the development of operating rules that drive the business of healthcare:
- Your organization can join CORE to participate directly in the rule development process,
- Achieve voluntary CORE Certification, and/or
- Endorse CORE.
As CAQH CORE continues to evolve its rule development processes, entities are encouraged to submit ideas for future operating rules or modifications to CORE@caqh.org.
CAQH CORE is in the process of drafting additional rules to respond to the third and final set of operating rules required by the ACA. If you are interested in learning more or participating, email CORE@caqh.org.
Interested stakeholders are encouraged to contact CAQH CORE to learn more about how to become a CORE Participant at CORE@caqh.org.
View the list of CORE Participating Organizations.
Education and Outreach
CAQH CORE is committed to educating the industry on the value of operating rules and how they build on standards. The scope of the CORE rules to date reflects the realities of how health plans and providers can use electronic transactions to move the industry forward while supporting current operations. The CORE rule development and voting processes are transparent and inclusive, and highlight the roles of those who need to implement the rules: health plans, clearinghouses/vendors, and providers.
CAQH CORE holds frequent education sessions with partners such as WEDI, associations, and Medicaid workgroups. Presentations often include speakers from organizations that have already implemented the rules. Additionally, CAQH CORE holds monthly, industry-wide free Town Hall calls to provide both non-CORE and CORE participants with an informal update on CAQH CORE activities, including activities related to the ACA Section 1104 Administrative Simplification provisions (e.g. status of regulations, CORE Rule development, etc.).
View the complete list of CORE Education Events (including copies of past sessions)
View the complete list of CAQH CORE Town Hall Calls (including recordings of past sessions)
Interested in having CAQH CORE present at your event/organization? Email CORE@caqh.org.
CAQH CORE has a number of resources and tools available to assist entities with implementation of the CAQH CORE EFT & ERA Operating Rules.
- Analysis & Planning Guide for Implementing the CAQH CORE EFT & ERA Operating Rules: Provides guidance for Project Managers, Business Analysts, System Analysts, Architects, and other project staff to complete systems and processes analysis & planning
- Outlines key tasks for pre-implementation analysis and planning for adoption of the CAQH CORE EFT & ERA Operating Rules and includes three tools to assist entities in completing analysis & planning:
- Stakeholder & Business Type Evaluation
- Systems Inventory & Impact Assessment Worksheet
- Gap Analysis Worksheet
- FAQs: Address typical questions regarding the CAQH CORE EFT and ERA Operating Rules (as well as other topics).
- Phase III CORE EFT & ERA Operating Rules Voluntary Certification Master Test Suite: Developed to support voluntary CORE Certification; includes information about key concepts, e.g., role of trading partners, that also apply for general implementation of the CAQH CORE Operating Rules
- Education Sessions: CAQH CORE holds frequent sessions with partners such as WEDI, associations, and Medicaid workgroups that often include speakers from organizations that have implemented the CAQH CORE Operating Rules
- Excel Copy of the CORE-required EFT Enrollment Data Set and Excel Copy of the CORE-required ERA Enrollment Data Set: To assist entities with their implementation of the CAQH CORE 380 Rule and the CAQH CORE 382 Rule, two Excel Workbooks are available containing the CORE-required Maximum EFT & ERA Enrollment Data Sets, i.e., Table 4.2-1 in the CAQH CORE 380 Rule and the CAQH CORE 382 Rule
- The purpose of these Excel copies is to enable easier loading of data element names and descriptions as HIPAA covered entities work to update their paper and electronic enrollment forms
- As a reminder, the CAQH CORE 380 Rule and the CAQH CORE 382 Rule require that the CORE-required Maximum EFT and ERA Enrollment Data Sets be used without revision or modification, and that the order of the data conforms to the flow, format, and data set (including data element descriptions) established in Table 4.2-1 of the rule; this requirement applies to both electronic enrollment data collection forms and manual paper-based forms, should a health plan or its agent offer a paper-based data collection process
- General/Clarifying Questions: After reviewing these tools & resources, please email CORE@caqh.org with any general questions or for additional clarification
For more information about the mandated operating rules process contact CAQH CORE at CORE@caqh.org.