Skip to content

Opportunity: Adopting Operating Rules with Attachment Standards

On December 19, 2022, the Department of Health and Human Services (HHS) issued a notice of proposed rulemaking (NPRM): Administrative Simplification: Adoption of Standards for Health Care Attachments Transactions and Electronic Signatures, and Modification to Referral Certification and Authorization Transaction Standard. The NPRM represents a watershed moment for the healthcare industry by naming the X12 275 and HL7 C-CDA as standards for the electronic exchange of attachments for health care claims and prior authorization. These provisions, among others included in the NPRM, provide a foundation for providers and health plans to sunset costly manual workflows used to send and receive supplemental medical information. In 2021, 76% of attachments transactions were carried out manually – using phone, fax, or other means – representing more than $200 million in potential medical industry cost savings (source: 2022 CAQH Index).

Limitations of the Standards and the Role of Operating Rules

The proposed standards present a robust initial framework for the electronic exchange of attachments, but on their own do little to prevent varying, non-uniform implementation, limiting the promise of interoperability. For example, while the proposed standards support the exchange of unsolicited attachments, they do not outline minimum requirements for what information providers must include to indicate that unrequested supporting documentation has been sent. If this data varies by transaction or is all together absent, reassociation can be complicated and costly manual workflows used to resolve any disputes may be perpetuated. This variation or exclusion of information is significant when scaled over the millions of attachment transactions carried out annually.

Operating rules, which are stipulated in the ACA and required for HIPAA-mandated transactions, are essential in minimizing business variation in the use of standards by defining how the technical and data content requirements contained within the standards should be applied to common business scenarios. CAQH CORE is the HHS-designated Operating Rule Authoring Entity and has directly contributed to the adoption and growth of electronic standards for HIPAA-mandated transactions. Consistent with this role, CAQH CORE has developed attachment operating rules that support the proposed standards and help automate the exchange of supplemental information for health care claim and prior authorization transactions.

CAQH CORE Attachment Operating Rules and a Call to Action

The attachments operating rules align the industry around consistent expectations for data content, infrastructure, and connectivity requirements and, as such, complement the proposed standards by minimizing the potential for variable business utilization. The CAQH CORE Attachments Operating Rules also include built in flexibility to update requirements as the industry evolves, ensuring that durable, interoperable frameworks can last into the future. The operating rules are not included for adoption in the NPRM, but are currently under consideration by the National Committee for Vital and Health Statistics (NCVHS) for recommendation for federal adoption, the first step in the federal mandate process. If NCVHS supports a mandate, the operating rules could be included in final rulemaking for concurrent adoption alongside standards, aligning implementation timelines and preventing further industry fragmentation.

Simultaneous implementation of operating rules and attachments standards is a powerful tool to prevent the promulgation of proprietary solutions and fragmented implementation. CAQH CORE is strongly encouraging industry stakeholders to submit their position on simultaneity through the following channels.

  1. Direct feedback to NCVHS: Due to the timing of the NCVHS hearing, public comment on the proposed attachments operating rules was due prior to the release of the NPRM for attachment standards. NCVHS committee members have requested additional industry feedback about the synergy between the proposed operating rules and the NPRM for attachment standards. These comments can be submitted to with the subject line [Comments: Aligning Attachments Operating Rules & Standards].
  2. Public Comment on the Proposed Rule: The NPRM for attachments standards is open for public comment, which can be submitted here. It would be beneficial for you or your organization to include your standing on simultaneous adoption of operating rules to help inform the decision at HHS. The 90-day comment window will close on March 21, 2023.

While CAQH CORE understands there is discussion underway regarding alignment between the proposed attachments standards and electronic prior authorization proposed rule, industry cannot afford to delay baseline attachments operating rule implementation. CAQH CORE staff is available to discuss the nuances of the operating rules and the HHS proposed rule to aid you in developing your comments. You need only reach out to Erin Weber, CAQH CORE Vice President, at to schedule time or ask a question. Our team is looking forward to engaging with you during this work.