Ongoing Maintenance of the EFT & ERA Enrollment Data Sets for CAQH CORE 380 & CAQH CORE 382 Rules

Current Versions of the CAQH CORE 380 & 382 EFT & ERA Enrollment Rules:  CORE 380 Rule v3.0.1 & CORE 382 Rule v3.0.1  
Status of the EFT & ERA Enrollment Data Sets Maintenance Process: 2015 Review complete; next Review scheduled for second half of 2016.

Keeping Up with the CORE-required Maximum Enrollment Data Sets

If you are tasked with implementing the CAQH CORE 380: EFT Enrollment Data Rule and the CAQH CORE 382: ERA Enrollment Data Rule, part of the Affordable Care Act (ACA)-mandated EFT & ERA CAQH CORE Operating Rules, you will find all the necessary tools and information here to comply with these operating rules.

These resources are provided free of charge by CAQH CORE, author of the operating rules, and are intended to help organizations comply with the Affordable Care Act (ACA).

Background

The CAQH CORE EFT & ERA Operating Rules support the healthcare industry's transition to electronic payment and remittance advice. Two of the five CAQH CORE EFT & ERA Operating Rules, the CAQH CORE 380 and CAQH CORE 382 Rules, address the barriers to greater provider EFT and/or ERA enrollment due to the variance in the required processes and data elements. The CAQH CORE 380 and CAQH CORE 382 Rules address these variances by outlining maximum sets of standard data elements (e.g., the CORE-required Maximum EFT & ERA Enrollment Data Sets) to be collected by a health plan or its agent during provider enrollment in EFT and/or ERA. The rules also outline a flow and format for electronic collection of the data elements (and paper-based forms if offered) among other requirements.

Section 3.4 in the CAQH CORE 380 and CAQH CORE 382 Rules recognizes the need for ongoing maintenance of the CORE-required Maximum EFT & ERA Enrollment Data Sets and requires establishment of a policy and process to review the Enrollment Data Sets on an annual basis. The first annual review of the CORE-required Maximum EFT & ERA Enrollment Data Sets was completed in August 2014 by the CAQH CORE Enrollment Data Task Group.

Current and Past Versions of CAQH CORE 380 and 382 Rules

The current versions of the CAQH CORE-required Maximum EFT & ERA Enrollment Data Sets are the CAQH CORE 380: EFT Enrollment Data Rule v3.0.1 and the CAQH CORE 382: ERA Enrollment Data Rule v3.0.1. As updated versions of the Enrollment Data Sets are published, the table below will be updated. 

CAQH CORE 380: EFT Enrollment Data Rule

CAQH CORE 382: ERA Enrollment Data Rule

Version

Substantive Adjustments between Versions

(Require entities to update systems/forms)

Non-substantive Adjustments between Versions

(DOES NOT require entities to update systems/forms)

Compliance Date

(Applies to all HIPAA-covered Entities)

Version

Substantive Adjustments between Versions

(Require entities to update systems/forms)

Non-substantive Adjustments between Versions

(DOES NOT require entities to update systems/forms)

Compliance Date

(Applies to all HIPAA-covered Entities)

Sept 2014 v3.0.1

(current version)

None

Examples of non-substantive adjustments to improve usability of data set include:

Address formatting inconsistencies and typos

Ensure consistency between data elements

Provide clarity on data elements that generated questions from implementers

N/A – Non-substantive Adjustments DO NOT require entities to update enrollment systems/forms

Sept 2014 v3.0.1

(current version)

None

Examples of non-substantive adjustments to improve usability of data set include:

Address formatting inconsistencies and typos

Ensure consistency between data elements

Provide clarity on data elements that generated questions from implementers

N/A – Non-substantive Adjustments DO NOT require entities to update enrollment systems/forms

June 2012 v3.0.0

(deprecated version)

N/A

 

January 1, 2014

June 2012 v3.0.0

(deprecated version)

N/A

 

January 1, 2014

NOTE: The CAQH CORE Enrollment Data Task Group agreed not to adjust the Enrollment Data Sets during its 2015 Review. 

Timeline for Updates and Compliance with Updated Enrollment Data Sets

Timeline for Updates to the Enrollment Data Sets

Per Task Group policy, the CAQH CORE Enrollment Data Task Group conducts two types of reviews, Comprehensive Reviews and Limited Reviews, which are described in the table below:

Comprehensive Review
Next Comprehensive Review: 2017
Limited Review
Next Limited Review: 2016

• A “Call for Submissions” of potential substantive and non-substantive adjustments to the Enrollment Data Sets occurs

• If adjustments are approved by Task Group, an updated Enrollment Data Set is published

• HIPAA-covered entities will need to update enrollment forms/systems

• Task Group only considers non-substantive adjustments to the Enrollment Data Sets based on industry experience with current Enrollment Data Sets

• If non-substantive adjustments are approved by Task Group, an updated Enrollment Data Set(s) is published

• HIPAA-covered entities will not need to update enrollment forms/systems

The CAQH CORE Enrollment Data Task Group convenes for Comprehensive Reviews (e.g. substantive and non-substantive adjustments) once every other year and convenes for a Limited Review (non-substantive adjustments only) on the “off” year. The next Review (2016) is scheduled to be a Limited Review.

NOTE: The Enrollment Data Task Group may elect to hold a Comprehensive Review in lieu of a Limited Review if any “emergency” substantive adjustments are identified; an “emergency” adjustment is defined as any adjustment necessary to resolve an issue prohibiting implementation of the current Enrollment Data Set for multiple implementers and/or to address a regulatory requirement.

Timeframe for Compliance with Updated Enrollment Data Sets

During the years when the CAQH CORE Enrollment Data Task Group conducts Comprehensive Reviews and agrees on substantive adjustments to the Enrollment Data Sets, a notification will be shared with the industry via email and on this webpage announcing the publication of updated Enrollment Data Sets. Per Task Group policy a health plan or its business associate has nine calendar months to update their electronic enrollment systems/forms and twelve calendar months to update their paper-based enrollment forms to comply with published, updated versions of the CORE-required Maximum EFT & ERA Enrollment Data Sets. The timeframe starts on the date that CAQH CORE published the updated versions of the Enrollment Data Sets to the industry. 

Status of CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process

Per the rule language, the CORE-required Maximum EFT & ERA Enrollment Data Sets are reviewed and updated on an annual basis. The CAQH CORE 380 and CAQH CORE 382 Rules require that the first review of the enrollment data sets commenced in Q2 2014, one year after the rules were adopted into federal regulation.The table below outlines the scope of the CAQH CORE EFT & ERA Enrollment Data Set Maintenance Process. 

The CAQH CORE Enrollment Data Task Group is responsible for maintaining the CAQH CORE EFT & ERA Enrollment Data Sets. The Task Group is co-chaired by:

  • Kiana Fitchett, Horizon Blue Cross Blue Shield of New Jersey
  • Minil Mikkili, Kaiser Permanente
  • Deirdre Ruttle, InstaMed

In keeping with the CAQH CORE multi-stakeholder, collaborative and transparent operating rule development process, the Task Group is open to representatives from any CORE Participating Organization, with no limit on the number of Task Group participants. Individuals with knowledge of the business processes and work flows for EFT and ERA enrollments are strongly encouraged to join the Task Group. If you would like to join the Task Group, please send your name, title, organization name, email address, and telephone number to core@caqh.org.

2014 Review

The CAQH CORE Enrollment Data Task Group convened in Q2 2014 to conduct its first Limited Review of the CORE-required Maximum EFT & ERA Enrollment Data Sets. During the Task Group's 2014 Limited Review, Task Group members:

  1. Identified and addressed non-substantive adjustments in the CORE-required Maximum EFT & ERA Enrollment Data Sets to improve implementer usability of the Enrollment Data Sets. The non-substantive adjustments do not require entities to update their electronic and paper-based enrollment methods. Examples of the non-substantive adjustments approved by the Task Group included:
    • Formatting inconsistencies and typos
    • Consistency between data elements
    • Clarity on data elements that generated questions from implementers
  2. Established key policies for an ongoing annual CAQH CORE Enrollment Data Sets Maintenance Process including:
    • Enrollment Data Evaluation Criteria
    • Collection of Supporting Information with Substantive Adjustment Submissions
    • Timeframes for Compliance with Updated Enrollment Data Sets
    • Scope of Annual Reviews

2015 Review

The CAQH CORE Enrollment Data Task Group convened in Q4 2015 to conduct its first Comprehensive Review of the CORE-required Maximum EFT & ERA Enrollment Data Sets. During the Task Group's 2015 Review, Task Group members reviewed the rationale for and against conducting a Comprehensive Review. Upon consideration, the Task Group elected NOT to conduct a Comprehensive Review. This decision was based on several factors, which included:

  • Industry resources better spent on higher-priority items such as ICD-10, completing implementations of mandated operating rules, and preparing for Phase IV implementation
  • Lack of an industry-wide call to action for adjustments to the Enrollment Data Sets, i.e. CAQH CORE did not receive any Requests related to the Data Sets in 2015
  • Current Data Sets are successfully implemented in the market, i.e. more than 30 organizations are Phase III CORE Certified and in conformance with the Data Sets

Additionally, the Task Group sought to collect non-substantive adjustments as part of a Limited Review. As no non-substantive adjustments were proposed, the Task Group did not update the Enrollment Data Sets in 2015. 

How to Submit Potential Substantive Adjustments to the Enrollment Data Sets

The CAQH CORE Enrollment Data Task Group will conduct its next Comprehensive Review in 2017. A Limited Review (non-substantive adjustments only) will occur in 2016. If you represent a CORE Participating Organization, email core@caqh.org to directly participate in the Task Group. More information on the next Comprehensive Review will be available in 2017.

When considering potential substantive adjustments to the Enrollment Data Sets, the Task Group will use the following Enrollment Data Evaluation Criteria to support decision-making. When submitting potential substantive adjustments, entities will be required to confirm their submission meets at least four of the seven criterion.

Enrollment Data Evaluation Criteria for Ongoing Maintenance

  1. Supports the vision of the CAQH CORE Enrollment Data Rules to move the industry toward a uniform, standard maximum set of required EFT and ERA enrollment data elements
  1. Promotes EFT and ERA enrollment efficiency (e.g., reduction in staff time and resources required to complete enrollment) and increases provider adoption by reducing the range of enrollment information requested and variation in terms used to collect the same/similar information
  1. Does not result in addition of data elements that are semantic variations of existing data elements; i.e., data elements must collect unique and distinctly separate information
  1. Meets a demonstrated, new or current industry-wide multi-stakeholder business need not addressed by the existing Enrollment Data Set
  1. Ensures collection of key items needed to fully automate both claims payment and remittance advice posting processes
  1. Balances return on investment (ROI) and industry-wide benefit against the significant lift required for health plans or agents to revise enrollment systems and paper-based forms and for providers to provide the data
  1. Consistent with Phase III CORE Guiding Principles

In addition to alignment with the Evaluation Criteria, the Enrollment Data Task Group’s policy is to collect Supporting Information with submissions for substantive adjustments to the Enrollment Data Sets. Based on lessons learned from other CAQH CORE maintenance processes, the Task Group will collect a Business Case and any applicable Supporting Data. The table below further describes the Supporting Information:

  1. Business Case (Required)
  1. Supporting Data (If applicable)

As part of a Business Case, submitters will be asked to describe:

  • Rationale/business need for the proposed substantive adjustment
  • Applicability of the proposed adjustments to key stakeholders
  • Expected outcome of proposed adjustment

Submitters will be given the option to submit any supporting data to strengthen their Business Case by providing:

  • Type of data reviewed
  • Timeframe of data reviewed
  • Summary of findings
  • Description of how findings support Business Case

Example: Collection of this data element during enrollment would allow for greater automation across all stakeholders. It is anticipated collection of this data element will reduce phone calls from providers by 20%.

Example: Over the last six months, health plan staff has had to call 40 provider organizations to collect this data element which took approximately 20 hours. Staff time could be freed up for other activities if this data element was included on the enrollment form.

Impact of Substantive Enrollment Data Set Updates

The CAQH CORE Enrollment Data Rule requirements and the impact of updated versions of the CORE-required Maximum EFT & ERA Enrollment Data Sets with substantive adjustments vary depending on an entity’s stakeholder type.

NOTE: ACA Section 1104 mandates that all HIPAA covered entities comply with the EFT & ERA Operating Rules; however non-HIPAA covered entities play a crucial role in enabling their provider and health plan clients to realize the benefits of industry adoption of the CAQH CORE Operating Rules and often act as Business Associates on behalf of a HIPAA covered entity.

 

Senders of the X12 v5010 835 & ACH CCD+

Receivers of the X12 v5010 835 & ACH CCD+

Applicable Stakeholder Types

Any organization with systems that enroll providers to receive claim payment and/or remittance information via the X12 v5010 835 and/or the ACH CCD+ such as:

  • Health plans
  • Health plan-facing clearinghouses
  • Health plan-facing vendors
  • Health plan business associates

Any organization with systems that receive the X12 v5010 835 and/or ACH CCD+ and thus must enroll to receive these transactions, which may include:

  • Providers
  • Provider-facing clearinghouses
  • Provider-facing vendors
  • Provider business associates

What requirements apply to my organization?

 

(Please refer to CAQH CORE 380 and CAQH CORE 382 Rules for a full list of applicable rule requirements)

  • All health plans, and their agents or vendors offering EFT and/or ERA enrollment, must use the maximum set of EFT and/or ERA enrollment elements with the required flow and format for presentation of the data elements
  • All health plans, and their agents or vendors offering EFT and/or ERA enrollment, must implement and offer an electronic method and process for collection and submission of the CORE-required Maximum EFT & ERA Enrollment Data Sets
  • Health plans , and their agents or vendors offering EFT and/or ERA enrollment, are NOT:
    • Required to use a paper-based EFT and/or ERA enrollment form if they do not currently do so. However, if a health plan chooses to use a paper-based form, the paper-based form must conform to the rule requirements
    • Prohibited from using a single inclusive form/method for the purposes of EFT and/or ERA Enrollment, as long as the format, flow, and data set (including data element descriptions) are used as given in Table 4.2-1 of each rule

N/A

What does my organization need to do when an updated version of the CORE-required Maximum EFT & ERA Enrollment Data Sets is published?

  • Update both electronic and paper-based EFT and/or ERA Enrollment forms to align with the updated versions of the CORE-required Maximum EFT & ERA Enrollment Data Sets within the compliance timeframe to be specified by the CAQH CORE Enrollment Data Task Group
  • Be aware that health plans and their business associates will be making adjustments to their electronic and paper-based enrollment methods to align with the updated versions of the CORE-required Maximum EFT & ERA Enrollment Data Sets
  • Monitor if health plans and their business associates have updated their electronic and paper-based forms to align with the updated CORE-required Maximum EFT & ERA Enrollment Data Sets; if non-compliance is identified:
    • Step 1: Communicate and work with health plans and business associates to update their systems
    • Step 2: Report non-compliance to CMS as appropriate

Get Involved in the EFT & ERA Enrollment Data Sets Maintenance Process

Entities are encouraged to join CAQH CORE as a CORE Participating Organization to:

  • Contribute to the evolution of the enrollment data sets in CAQH CORE 380 and 382 Rules via the CAQH CORE Enrollment Data Task Group
  • Have a voice in the development of operating rules
  • Be part of a solution that is taking cost and complexity out of the healthcare system

CAQH CORE welcomes Participating Organizations representing a range of stakeholder groups.

Entities can also contribute a number of other ways, for example:

  • Attend CAQH CORE Town Hall Calls
    • CAQH CORE holds bimonthly Town Hall calls to provide attendees an update on recent activities including status of the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process; enter your contact information in the section below to be added to the distribution list
  • Respond to public surveys or submit requests to CORE@caqh.org

Trading Partner Collaboration: Conformance Testing and Voluntary CORE Certification

  • Conformance testing with your trading partners is a critical aspect to making your operating rules implementation a success
    • HIPAA covered entities can quickly communicate their organization’s readiness to testing their conformance with trading partners by adding their company information to the CORE Partner Testing page of the CAQH website
    • Entities should consider voluntary CORE Certification to publicly communicate their systems meet the CAQH CORE EFT & ERA Operating Rule requirements

Contact CAQH CORE

CORE EFT ERA Enrollment data set

Complete the form below to:

  • Receive general information on CAQH CORE; including updates regarding the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process
  • Receive information on becoming a CORE Participating Organization
  • Submit a question or feedback to CAQH CORE
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