Frequently Asked Questions - II. Interdependent CAQH CORE Payment & Remittance Requirements

NACHA – The Electronic Payments Association is the Standards Development Organization (SDO) that maintains the ACH Corporate Credit or Debit with Addenda Record (CCD+) standard format. NACHA develops rules, published in the NACHA’s Healthcare Resource Site, which govern electronic transmissions conducted through the ACH Network. The HHS Final Rule adopting the Healthcare EFT Standards (CCD+ and X12 v5010 835 TR3 TRN Segment) adopts the implementation specifications in the NACHA Operating Rules & Guidelines as the HIPAA-mandated standard for the CCD+.

NOTE: NACHA updates its operating rules and guidelines every year with a new version for use by financial institutions. Per CMS, any version of the NACHA Operating Rules & Guidelines can be used as long as the implementation specifications for the CCD+ do not differ from those in the 2011 version.

The CAQH CORE Payment & Remittance Operating Rules do not change the meaning, usage, or definition of the X12 v5010 835 data elements.

Use of the X12 v5010 835 BPR Segment data elements is referenced in the following sections of the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule vPR.1.0:

• Table 3.3-1 in Section 3.3, CORE-required Minimum CCD+ Data Elements for Successful Reassociation, identifies the CORE-required minimum set of CCD+ data elements necessary for successful reassociation of the CCD+ and the X12 v5010 835. The CORE-required Minimum CCD+ Reassociation Data Elements include CCD+ Record #5, Field 9, Effective Entry Date, CCD+ Record #6, Field 6, Amount, and CCD+ Record #7, Field 3, Payment Related Information. CCD+ Records #5 and #6 correspond to BPR16 Date (EFT Effective Date) and BPR02 Monetary Amount (Total Actual Provider Payment Amount) respectively in the X12 v5010 835. BPR16 and BPR02 provide information required for the successful reassociation of the X12 v5010 835 and the CCD+.
• Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transaction, specifies requirements for health plans to ensure that the CCD+ Effective Entry Date is a valid banking day and that the corresponding X12 v5010 835 BPR16 (EFT Effective Date) is the same valid banking day.

Please Note: Guidance on implementation of the X12 v5010 835 TR3 implementation guide, and its underlying standard, should be obtained from ASC X12, the Standards Development Organization (SDO) that develops and maintains the X12 v5010 835 standard. Information related to the meaning, use, and interpretation of ASC X12 Standards, Guidelines, and Technical Reports can be obtained via the ASC X12 website.

Yes, inclusion of a health plan TIN is required for the X12 v5010 835 TR3 TRN Segment component of the Healthcare EFT Standards.

The January 2012 HHS Final Rule for the HIPAA-mandated EFT transaction standard adopts the NACHA CCD+ and the X12 v5010 835 TR3 Reassociation Trace Number (hereafter TRN) Segment together as the Healthcare EFT Standards. The NACHA Operating Rules do not require use of a TIN in the CCD+ component of the Healthcare EFT Standards. However, the X12 v5010 835 TR3 Implementation Guide does require inclusion of the health plan/payer’s TIN in the TRN03 data element within the X12 v5010 835 TR3 TRN Segment. The CAQH CORE Payment & Remittance Operating Rules do not change the meaning, usage, or definition of the X12 v5010 835 data elements or the CCD+ data fields.

Beyond the standard requirements, use of the X12 v5010 835 TR3 TRN Segment is referenced in Table 3.3-1 in Section 3.3, CORE-required Minimum CCD+ Data Elements for Successful Reassociation, of the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule vPR.1.0. Table 3.3-1 identifies the CORE-required minimum set of CCD+ data elements necessary for successful reassociation of the CCD+ and the X12 v5010 835 and their corresponding data elements in the X12 v5010 835:

Please Note: Guidance on implementation of the X12 v5010 835 TR3 implementation guide, and its underlying standard, should be obtained from ASC X12, the Standards Development Organization (SDO) that develops and maintains the X12 v5010 835 standard. Information related to the meaning, use, and interpretation of ASC X12 Standards, Guidelines, and Technical Reports can be obtained from ASC X12 via the ASC X12 website. NACHA – The Electronic Payments Association is the SDO that maintains the CCD+ standard format. For questions related to the CCD+, or to NACHA in general, contact Brad Smith, Senior Director, at bsmith@nacha.org or visit NACHA’s Healthcare Resource Site.

Submission of a healthcare claim and the payment of the claim (and delivery of the applicable remittance advice) are separate transactions. A provider may receive healthcare EFT and/or ERA in response to claims submitted both via paper and electronic methods. Currently, many providers submit paper-based claims to health plans and receive claim payment and remittance via the healthcare EFT and ERA standard transactions. For example, a provider may be required to send a claim that requires a clinical attachment via paper to the health plan but choose to receive an EFT and ERA.

The CAQH CORE Payment & Remittance Operating Rules apply specifically to the use, conduct, or processing of the ASC X12 005010X221A1 Health Care Claim Payment/Advice (835) transaction and the HIPAA-mandated Healthcare EFT Standards (the NACHA CCD+ and X12 v5010 835 TR3 TRN Segment). Therefore, if a provider submits a paper-based claim to a health plan and receives back from the health plan claim payment and remittance via the X12 v5010 835 and/or HIPAA-mandated Healthcare EFT Standards transactions, the CAQH CORE Payment & Remittance Operating Rules would apply.

In sum: A health plan’s use of the healthcare EFT and ERA to provide payment and remittance to a provider is independent of the method in which the healthcare claim was submitted (paper or electronic).

Yes, if the X12 v5010 835 TRN Reassociation Trace Number Segment (hereafter TRN Segment) is a valid segment with acceptable delimiters per the NACHA Operating Rules and does not exceed the 80 character overall maximum as required by the NACHA Operating Rules. The CAQH CORE Payment & Remittance Operating Rules do not change the meaning, usage, or definition of the X12 v5010 835 data elements or the NACHA CCD+ data fields.

Use of the X12 v5010 835 TRN Segment data elements is referenced in Table 3.3-1 in Section 3.3, CORE-required Minimum CCD+ Data Elements for Successful Reassociation, of the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule vPR.1.0. Table 3.3-1 identifies the CORE-required minimum set of CCD+ data elements necessary for successful reassociation of the CCD+ and the X12 v5010 835. The CORE-required Minimum CCD+ Reassociation Data Elements include CCD+ Record #5, Field 9, Effective Entry Date, CCD+ Record #6, Field 6, Amount, and CCD+ Record #7, Field 3, Payment Related Information.

CCD+ Record #7 Field 3 corresponds to the X12 v5010 835 TRN Segment. As identified in the table, the X12 v5010 835 TRN Segment is composed of three required data elements (TRN01-481 Trace Type Code, TRN02-127 Reference Identification, and TRN03-509 Originating Company Identifier) and one situational data element (TRN04-127 Reference Identification). Combined with the X12 v5010 835 data elements from the BPR segment (BPR16 and BPR02), the X12 v5010 835 TRN Segment provides information required for the successful reassociation of the X12 v5010 835 and the CCD+.

For further guidance on these requirements, please see the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule vPR.1.0.

Please Note:  Information related to the meaning, use, and interpretation of ASC X12 Standards, Guidelines, and Technical Reports can be obtained from ASC X12 via its online ASC X12 website. NACHA – The Electronic Payments Association is the SDO that maintains the CCD+ standard format. For questions related to the CCD+, or to NACHA in general, contact Brad Smith, Senior Director, at bsmith@nacha.org or visit NACHA’s Healthcare Resource Site.