Operating Rules Mandate -
Claim Status and Eligibility
Getting Involved with CAQH CORE | Education and Outreach | Implementation Resources | Contacts
Status of Mandated Eligibility and Claim Status Operating Rules
All HIPAA-covered entities are required by Federal law to adopt the Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules* by January 1, 2013.
In 2010 the National Committee on Vital and Health Statistics (NCVHS) Subcommittee on Standards, an advisory body to the Department of Health and Human Services (HHS), held hearings on mandated operating rules for eligibility and claim status transactions in response to administrative simplification provisions in Section 1104 of the Patient Protection and Affordable Care Act (ACA). CAQH CORE provided testimony at these hearings. NCVHS then issued a letter in September 2010 to the Secretary of HHS recommending adoption of the Phase I & II CAQH CORE Operating Rules for Eligibility & Claim Status. In July 2011, the Centers for Medicare and Medicaid Services (CMS) published an Interim Final Rule with Comment, CMS-0032-IFC: Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions, with the following key features:
- Adopted the Phase I & II CAQH CORE Operating Rules for the Eligibility & Claim Status transactions, except for rule requirements pertaining to Acknowledgements
- Highlighted CORE Certification is voluntary
- Further defined the relationship between standards and operating rules and included an analysis of ROI from operating rules implementation
In December 2011, CMS issued a notice adopting CMS-0032-IFC as a Final Rule and industry implementation efforts are underway for the January 1, 2013 effective date for implementation of the Federally mandated CAQH CORE Eligibility & Claim Status Operating Rules.
In June 2012, CAQH CORE and several other organizations gave testimony to the NCVHS Subcommittee on Standards. As the authoring entity of operating rules for eligibility and claim status, CAQH CORE provided its perspective on how stakeholders are preparing to implement the mandated rules.
The CAQH CORE Eligibility & Claim Status Operating Rules are available on the CAQH website:
See here for a high-level overview of the Phase I & II CAQH CORE Operating Rule requirements and clinical alignment.
*NOTE: In the Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction, CAQH CORE requirements pertaining to use of Acknowledgements are NOT included for adoption. Although HHS is not requiring compliance with any operating rule requirements related to Acknowledgements, the Final Rule does note “we are addressing the important role acknowledgements play in EDI by strongly encouraging the industry to implement the acknowledgement requirements in the CAQH CORE rules we are adopting herein.”
Immediate Action Required for Eligibility and Claim Status
January 1, 2013 Effective Date: Implementation efforts should be complete at all HIPAA covered entities to adopt the Federally mandated CAQH CORE Eligibility & Claim Status Operating Rules by the January 1, 2013 Effective Date.
Note: On January 2, 2013, CMS announced a 90-day period of enforcement discretion for compliance with Eligibility and Claim Status Operating Rules.
CAQH CORE Trading Partner Testing Readiness Page: Organizations that are ready to test operating rules implementation with trading partners are encouraged to add a contact to the new page highlighting readiness for the January 1, 2013 Eligibility and Claim Status Operating Rules implementation deadline.
Contact CORE@caqh.org with questions regarding this deadline.
Key Dates for Eligibility and Claim Status
The following dates are critical for industry implementation of the Federally mandated CAQH CORE Eligibility & Claim Status Operating Rules. Note there are two types of penalties related to compliance with the mandated operating rules.
- January 1, 2013: Effective Date by which HIPAA-covered entities must comply with the Federally mandated CAQH CORE Eligibility & Claim Status 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, 2013 for the eligibility and claim status 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 Eligibility & Claim Status 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 Eligibility & Claim Status 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 plan’s 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.
Role of CORE for Eligibility and Claim Status
CAQH CORE was selected by HHS as the authoring entity for the first set of Federally mandated operating rules for the eligibility and claim status transactions. Additionally, 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 have been recommended by NCVHS to HHS to meet 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 Eligibility and Claim Status
The Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules have been Federally mandated under the ACA. 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.
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 Eligibility & Claim Status Operating Rules.
- Analysis & Planning Guide for Adopting the CAQH CORE Eligibility & Claim Status Operating Rules: Provides guidance for Project Managers, Business Analysts, System Analysts, Architects, and other project staff to complete systems analysis & planning
- Outlines key tasks for pre-implementation analysis and planning for adoption of the CAQH CORE Eligibility & Claim Status 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 Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules
- Phase I & Phase II CORE Certification Master Test Suites: Initially developed to support voluntary CORE Certification however include information about key concepts, e.g., role of trading partners, that also apply for general adoption 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
- Medicaid Guidance from CMS: The Center for Medicaid and SCHIP services (CMCS) distributed a letter providing Medicaids guidance on section 1104 of the Affordable Care Act, which describes requirements for the adoption of operating rules for Eligibility for a Health Plan and Health Care Claim Status Transactions.
- General/Clarifying Questions: After reviewing these tools & resources, please email CORE@caqh.org with any general questions or for additional clarification
- CAQH CORE Trading Partner Testing Readiness Page: Organizations that are ready to test operating rules implementation with trading partners are encouraged to add a contact to the new page highlighting readiness for the January 1, 2013 Eligibility and Claim Status Operating Rules implementation deadline.
For more information about the mandated operating rules process contact CAQH CORE at CORE@caqh.org.