Ongoing Maintenance of the EFT & ERA Enrollment Data Sets

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  

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 no less than annually. From 2014 - 2020, review of the Enrollment Data Sets was conducted annually, with limited in-scope submissions from the industry and no substantive adjustments to the data sets. 

As such, CAQH CORE Participants elected to transition the EFT/ERA Maintenance Process to an ongoing, "rolling submission" process whereby adjustments can be submitted at any point in time rather than only during the annual review periods. The updated process allows industry to review the data sets on a continuous basis, in accordance with Section 3.4 CAQH CORE Process for Maintaining CORE-Required Maximum EFT/ERA Enrollment Data Sets. CAQH CORE will publicly track all submission on this webpage for transparency.

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)

May 2020 vPR.1.0

(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

May 2020 vPR.1.0

(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

Sept 2014 v3.0.1

(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

Sept 2014 v3.0.1

(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

June 2012 v3.0.0

(deprecated version)

N/A

 

January 1, 2014

June 2012 v3.0.0

(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

If CAQH CORE receives substantive submissions and/or critical needs are identified per the definitions below, the CAQH CORE Enrollment Data Task Group will convene to review the potential update to the Enrollment Data Sets.

  • Substantive submissions: More than one of the same, in-scope submissions that meet the Enrollment Data Evaluation Criteria for Ongoing Maintenance.
  • Critical needs: Any adjustment necessary to resolve an issue prohibiting implementation of the currently Enrollment Data Set for multiple implementers and/or to address a regulatory requirement.

Timeframe for Compliance with Updated Enrollment Data Sets

If the CAQH CORE Enrollment Data Task Group convenes to review a submitted substantive submission and/or critical need and agrees to the substantive adjustment(s) 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 on-going 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. 

EFT & ERA Enrollment Data Sets Maintenance Process

The CAQH CORE Enrollment Data Task Group is responsible for maintaining the CAQH CORE EFT & ERA Enrollment Data Sets and convenes when in-scope substantive submissions are received. 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.

How to Submit Potential Substantive Adjustments to the Enrollment Data Sets

If you represent a CORE Participating Organization, email core@caqh.org to submit a potential adjustment to the Enrollment Data Sets. 

When considering potential substantive adjustments to the Enrollment Data Sets, the Task Group Co-chairs and CAQH CORE Staff 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 CAQH 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 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:

  • 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 EFT Enrollment Data and CAQH CORE ERA Enrollment Data 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

Submitted Enrollment Data Set Adjustments

Given the submission process allows industry to review the data sets on a continuous basis, CAQH CORE will publicly track all submissions here for transparency.

2021

  • No submissions to date.
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