Operating Rules Mandate

ACA Federal Mandate for Healthcare Operating Rules

The Patient Protection and Affordable Care Act (ACA), Section 1104 “…establishes new requirements for administrative transactions that will improve the utility of the existing HIPAA transactions and reduce administrative costs.” ACA Section 1104 requires the Secretary of the Department of Health and Human Services (HHS) to adopt and regularly update standards, implementation specifications, and operating rules for the electronic exchange and use of health information for the purposes of financial and administrative transactions. ACA Section 1104 applies to HIPAA covered entities and business associates engaging in HIPAA standard transactions on behalf of covered entities. 

Operating rules are defined in the Affordable Care Act as the “necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications." Operating rules specify the information that must be included when conducting standard transactions covered under HIPAA, making it easier for providers to use electronic means to handle administrative transactions.

View the CMS website for more detail on the Administrative Simplification provisions of the ACA.

Learn how CMS enforces Administrative Simplification requirements by watching this video.

ACA Section 1104 Transactions Requiring Operating Rules

ACA Section 1104 required development of operating rules to address and support administrative transactions covered under HIPAA. CAQH CORE is designated by the Secretary of the Department of Health and Human Services (HHS) as the Operating Rule Authoring Entity for the HIPAA-mandated administrative transactions. 

 
Eligibility & Benefits,
Claim Status
Payment & Remittance
Other 
Transactions
Adoption Deadline
7/1/2011
7/1/2012
TBD
Effective Date
1/1/2013
1/1/2014
TBD

CAQH CORE

Operating Rules

Eligibility & Benefits and Claim Status Payment & Remittance  

Phases to Business Transactions Naming Conventions: Currently Adopted Operating Rules

In May 2020 CAQH CORE updated its phase-based operating rule structure to align with the business processes supported by the rules. Therefore, rather than five phases of operating rules spanning seven transactions, under the new structure there are seven sets of operating rules organized by healthcare business processes. This change aligns with current stakeholder operations, enhances flexibility to update requirements, enables more rapid and targeted rule development efforts, and eliminates the potential for an infinite number of future operating rule phases. As a result of this transition, the CAQH CORE Operating Rule naming and versioning conventions were updated. No substantive changes were made to the operating rules requirements. Therefore, conformance with the updated operating rules will result in conformance with the federally mandated operating rule requirements. CAQH CORE has provided links to the federally mandated versions of the operating rules for reference below along with a crosswalk to the new naming and versioning conventions. Click here for more information on the new operating rules structure.

Former Operating Rule Name

Former Version

Current Operating Rule Name

Current Version

CAQH CORE ELIGIBILITY & BENEFITS (EB) OPERATING RULE SET

Phase I CORE 152: Eligibility and Benefit Real Time Companion Guide Rule

v1.1.0

CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule

 

All eligibility infrastructure requirements combined into a single infrastructure rule.

 

 

 

 

 

 

 

 

 

 

vEB.1.0

Phase I CORE 155: Eligibility and Benefits Batch Response Time Rule

v1.1.0

Phase I CORE 156: Eligibility and Benefits Real Time Response Time Rule

v1.1.0

Phase I CORE 157: Eligibility and Benefits System Availability Rule

v1.1.0

Phase I CORE 154: Eligibility and Benefits 270/271 Data Content Rule

v1.1.0

CAQH CORE Eligibility & Benefits (270/271) Data Content Rule

 

All eligibility data content requirements combined into a single data content rule.

vEB.1.0

Phase II CAQH CORE 260: Eligibility & Benefits Data Content (270/271) Rule

v2.1.0

Phase II CAQH CORE 258: Eligibility and Benefits 270/271 Normalizing Patient Last Name Rule

v2.1.0

Phase II CAQH CORE 259: Eligibility and Benefits 270/271 AAA Error Code Reporting Rule

v2.1.0

Phase I CORE 153: Eligibility and Benefits Connectivity Rule

v1.1.0

CAQH CORE Connectivity Rule

vC1.1.0

Phase II CAQH CORE 270: Connectivity Rule

v2.2.0

CAQH CORE Connectivity Rule

vC2.2.0

CAQH CORE CLAIM STATUS (CS) OPERATING RULE SET

Phase II CAQH CORE 250: Claim Status Rule

v2.1.0

CAQH CORE Claim Status (276/277) Infrastructure Rule

vCS.1.0

Phase II CAQH CORE 270: Connectivity Rule

v2.2.0

CAQH CORE Connectivity Rule

vC2.2.0

CAQH CORE PAYMENT & REMITTANCE (PR) OPERATING RULE SET

Phase III CORE 350 Health Care Claim Payment/Advice (835) Infrastructure Rule

v3.0.0

CAQH CORE Payment & Remittance (835) Infrastructure Rule

vPR.1.0

Phase III CORE 360 Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule

v3.0.0

CAQH CORE Payment & Remittance (835) Uniform Use of CARCs and RARCs Rule

vPR.1.0

Phase III CORE 370 EFT & ERA Reassociation (CCD+/835) Rule

v3.0.0

CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule

vPR.1.0

Phase III CORE 380 EFT Enrollment Data Rule

v3.0.0

CAQH CORE Payment & Remittance EFT Enrollment Data Rule

vPR.1.0

Phase III CORE 382 ERA Enrollment Data Rule

v3.0.0

CAQH CORE Payment & Remittance ERA Enrollment Data Rule

vPR.1.0

Phase II CAQH CORE 270: Connectivity Rule

v2.2.0

CAQH CORE Connectivity Rule

vC2.2.0

CAQH Program