Operating Rules Mandate

ACA Federal Mandate for Healthcare Operating Rules

Section 1104 of the Patient Protection and Affordable Care Act (ACA) “…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.

View the CMS website for more detail on the Administrative Simplification provisions of the Affordable Care Act of 2010 (ACA).

What the Legislation Requires

ACA Section 1104 applies to HIPAA covered entities and business associates engaging in HIPAA standard transactions on behalf of covered entities. The legislation requires that the standards and associated operating rules adopted by the Secretary will:

  • Enable the determination of an individual’s eligibility and financial responsibility for specific services prior to or at the point of care;
  • Be comprehensive, requiring minimal augmentation by paper or other communications;
  • Provide for timely acknowledgement, response, and status reporting that supports a transparent claims and denial management process (including adjudication and appeals); and
  • Describe all data elements (including reason and remark codes) in unambiguous terms, require that such data elements be required or conditioned upon set values in other fields, and prohibit additional conditions (except where necessary to implement State or Federal law, or to protect against fraud and abuse).

Health plans must file a statement with HHS confirming compliance with the standards and operating rules; financial penalties for health plans are significant.

ACA Section 1104 Transactions Requiring Operating Rules

ACA Section 1104 requires development of three sets of operating rules to address and support a range of administrative transactions.

 
Eligibility and
Claim Status
EFT/ERA
Other 
Transactions*
Adoption Deadline
7/1/2011
7/1/2012
TBD
Effective Date
1/1/2013
1/1/2014
TBD

 

*Section 1104 of the ACA includes an adoption date of 7/1/2014 and effective date of 1/1/16 however HHS has not yet adopted operating rules or issued guidelines regarding the compliance timeframe for these transactions.

 

CAQH Program: