Current Versions of the CAQH CORE Payment & Remittance EFT & ERA Enrollment Data Rules: EFT Enrollment Data Rule PR.1.0 & ERA Enrollment Data Rule PR.1.0
Status of the EFT & ERA Data Sets Maintenance Process: 2020 Limited Review Complete. Next Comprehensive Review scheduled for Q4 2021
Keeping Up with the CORE-required Maximum Enrollment Data Sets
If you are tasked with implementing the EFT & ERA Enrollment Data Rules, part of the Affordable Care Act (ACA)-mandated CAQH CORE Payment & Remittance 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 Payment & Remittance Operating Rules support the healthcare industry's transition to electronic payment and remittance advice. Two of the five CAQH CORE Payment & Remittance Operating Rules address the barriers to greater provider EFT and/or ERA enrollment due to the variance in the required processes and data elements. The EFT & ERA Enrollment Data 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.
The EFT & ERA Enrollment Data Rules also recognize 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 ENROLLENT DATA Rules
The current versions of the CAQH CORE-required Maximum EFT & ERA Enrollment Data Sets are the CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 and the CAQH CORE Payment & Remittance ERA Enrollment Data Rule vPR.1.0. As updated versions of the Enrollment Data Sets are published, the table below will be updated.
|
CAQH CORE EFT Enrollment Data Rule |
CAQH CORE 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) |
|
(current version) |
None |
Re-organization of operating rules into rule sets organized by business transaction rather than phase as approved by the CAQH CORE Board in 2019. Operating rule naming, versioning and numbering methodologies updated to align with business transaction-based rule sets. |
N/A – Non-substantive Adjustments DO NOT require entities to update enrollment systems/forms |
(current version) |
None |
Re-organization of operating rules into rule sets organized by business transaction rather than phase as approved by the CAQH CORE Board in 2019. Operating rule naming, versioning and numbering methodologies updated to align with business transaction-based rule sets. |
N/A – Non-substantive Adjustments DO NOT require entities to update enrollment systems/forms |
|
(deprecated 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 |
(deprecated 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 |
|
(deprecated version) |
N/A |
|
January 1, 2014 |
(deprecated version) |
N/A |
|
January 1, 2014 |
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:
|
|
|
|
• Review of potential substantive and non-substantive adjustments. • 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 (2020) 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 EFT & ERA Enrollment Data Set Rules require that the first review of the enrollment data sets commence 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
- Zach VanTrieste, 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:
- 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
- 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.
2016 Review
The CAQH CORE Enrollment Data Task Group convened in Q4 2016 to conduct a Limited Review of the CORE-required Maximum EFT & ERA Enrollment Data Sets. During the 2016 Limited Review, no submissions for non-substantive adjustments (or otherwise) to the Enrollment Data Sets were received. Given this, the Data Sets in the current versions of the CAQH CORE EFT & ERA Enrollment Data Rules were not updated in 2016.
2017 Review
Per CAQH CORE Enrollment Data Task Group policy, the 2017 Enrollment Data Set Review was scheduled to be a “Comprehensive Review”. However, based on industry feedback via webinar polling, the CAQH CORE Request Process and discussions with key stakeholders, the Task Group Co-Chairs agreed that the Enrollment Data Sets were meeting the industry’s business needs and resources would be better spent addressing other items. No substantive adjustments were made to the Enrollment Data Sets.
In lieu of a Comprehensive Review in 2017, the Co-Chairs agreed to collect feedback from the CAQH CORE Participants on future potential needs related to the CAQH CORE Enrollment Data Rules via a brief questionnaire to help ensure future maintenance efforts target any issues related to the Enrollment Data Sets while respecting the industry resources required to conduct Comprehensive Reviews and implement substantive updates to enrollment forms/systems.
2018 Review
The CAQH CORE Enrollment Data Task Group convened in Q4 2018 to conduct a Limited Review of the CORE-required Maximum EFT & ERA Enrollment Data Sets. During the 2018 Limited Review, no submissions for non-substantive adjustments (or otherwise) to the Enrollment Data Sets were received. Given this, the Data Sets in the current versions of the CAQH CORE 380 EFT & ERA Enrollment Data Rules were not updated in 2018.
2019 Review
Per the CAQH CORE Enrollment Data Task Group policy, the 2019 Enrollment Data Set Review was a Comprehensive Review. The CAQH CORE EFT & ERA Enrollment Data Set Comprehensive Review Survey was distributed to all CAQH CORE Participating Organizations on Friday 11/15/19 and closed on Friday 12/13/19, giving respondents four weeks to complete the survey.
Only one in-scope substantive submission was received in response to the survey, requesting the removal of optional data elements. Based on this, Enrollment Data Task Group Co-chairs and staff agreed not to convene the Task Group to discuss the submission to balance industry-wide benefit against the significant lift required to remove an optional data element for health plans or their agent from their enrollment systems and paper based forms. The submission will be included as a consideration in future reviews.
2020 Review
A Limited Review of the CORE-required Maximum EFT & ERA Enrollment Data Sets was conducted in Q4 2020. During the 2020 Limited Review, no submissions for non-substantive adjustments (or otherwise) to the Enrollment Data Sets were received. Given this, the Data Sets in the current versions of the CAQH CORE 380 EFT & ERA Enrollment Data Rules were not updated in 2020 and the Enrollment Data Task Group did not convene.
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 2021. 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 late 2021.
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 |
|
|
|
|
|
|
|
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:
|
|
|
As part of a Business Case, submitters will be asked to describe:
|
Submitters will be given the option to submit any supporting data to strengthen their Business Case by providing:
|
|
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 Payment & Remittance 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:
|
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:
|
|
What requirements apply to my organization?
(Please refer to CAQH CORE EFT Enrollment Data and CAQH CORE ERA Enrollment Data Rules for a full list of applicable rule requirements) |
|
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? |
|
|
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 Enrollment Data 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.
Voluntary CORE Certification
- CAQH certifies and awards CORE Certification Seals to entities that create, transmit, or use the healthcare administrative and financial transactions addressed by the CAQH CORE Operating Rules. CORE Certification means an entity has demonstrated that its IT system, or product, is operating in conformance with applicable requirements of a specific phase(s) of the CAQH CORE Operating Rules.
- If you are a health plan, provider, clearinghouse, or vendor interested in information related to the CORE Certification please click HERE.
