Frequently Asked Questions - I. General CAQH CORE Payment & Remittance Operating Rules

Who should implement the CAQH CORE Payment & Remittance Operating Rules?

Submitted by jporras on Tue, 12/08/2020 - 11:39
Who should implement the CAQH CORE Payment & Remittance Operating Rules?

The CAQH CORE EFT & ERA Operating Rules apply to all HIPAA covered entities that conduct the X12 005010X221A1 Health Care Claim Payment/Advice (835) and the HIPAA-mandated Healthcare EFT Standards (NACHA CCD+ and the X12 v5010 835 TR3 TRN Segment) transactions. ACA Section 1104 requires all HIPAA covered entities to comply with the HIPAA-mandated payment and remittance operating rules. Entities acting in the role of a Business Associate of a HIPAA covered entity may also need to implement various aspects of the CAQH CORE EFT & ERA Operating Rules.

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What are the HIPAA-mandated Healthcare EFT Standards?

Submitted by jporras on Mon, 12/21/2020 - 08:36
What are the HIPAA-mandated Healthcare EFT Standards?

ACA Section 1104(c)(2) added the EFT transaction to the list of electronic health care transactions for which the HHS Secretary must adopt a HIPAA standard. In January 2012, HHS issued an Interim Final Rule with Comment (IFC) adopting the NACHA CCD+ and the X12 v5010 835 TR3 TRN Segment together as the Healthcare EFT Standards. On July 10, 2012, CMS announced that the IFC is a Final Rule now in effect. The CMS announcement notes that “we have decided not to change any of the policies established in CMS-0024-IFC.” More information on the Healthcare EFT Standards is available on the CMS website.

NOTE: The HHS Final Rule adopting the Healthcare EFT Standards does not prohibit use of other EFT transaction standards (e.g., Fedwire, card payment networks, CTX, etc.) to make electronic healthcare claim payments. However, if a provider requests that a health plan conduct EFT using the ACH Network, the health plan is required to do so.

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My health plan provides the X12 v5010 835 via an online application only, do the CAQH CORE Payment & Remittance (835) Infrastructure Rule requirements apply?

Submitted by msingh@caqh.org on Wed, 04/20/2022 - 15:41
My health plan provides the X12 v5010 835 via an online application only, do the CAQH CORE Payment & Remittance (835) Infrastructure Rule requirements apply?

​​​​​​The CAQH CORE Operating Rules apply to HIPAA transactions, which are healthcare electronic data interchanges (EDI); as such, the CAQH CORE Payment & Remittance (835) Infrastructure Rule does not apply when the X12 v5010 835 is provided via Direct Data Entry. However, CAQH CORE Payment & Remittance (835) Infrastructure Rule, Section 4.1, Health Care Claim Payment/Advice Connectivity Requirements requires health plans and other information sources to support the CAQH CORE Connectivity Rule to transmit the X12 v5010 835 ERA to providers. Thus, while health plans may continue to offer the X12 v5010 835 via DDE, use of a website only to provide the X12 v5010 835 to providers does not satisfy the connectivity requirements of the CAQH CORE Payment & Remittance (835) Infrastructure Rule.

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