CAQH CORE Payment & Remittance Operating Rules

No. The CAQH CORE 380 Rule, Section 4.5 specifies that “If a health plan or its agent does not use a paper-based manual method and process to collect the CORE-required Maximum EFT Enrollment Data Set as of the compliance date specified in any Federal regulation adopting this CORE Rule, it is not required by this rule to implement a paper-based manual process on or after the compliance date.”

NOTE: The CAQH CORE 380 Rule addresses electronic and paper-based collection and submission of the enrollment data. It does not specify the health plan’s internal enrollment process.

Section 4.3.2 of the CAQH CORE 380 Rule, requires that the CORE-required Maximum EFT Enrollment Data Set be used without revision or modification, and that the order of the data conforms to the flow, format, and data set (including data element descriptions) established in Table 4.2-1 of the rule. This requirement applies to both electronic enrollment data collection forms and manual paper-based forms, should a health plan or its agent offer a paper-based data collection process. In order to comply with the CAQH CORE 380 Rule requirements a health plan (or its agent or a vendor offering EFT) must not modify or vary the CORE EFT enrollment form template and EFT enrollment forms must follow the flow, format, and data set as specified in the rule.

The CAQH CORE 380 Rule establishes a maximum set of data elements for both paper and electronic EFT enrollment data collection and submission. This maximum set of CORE-required EFT Enrollment Data Elements is specified in Table 4.2-1 of the rule, organized by categories of information referred to as “Data Element Groups”. The CAQH CORE 380 Rule, Section 4.3 and its subsections specify the requirements for how the CORE-required Maximum EFT Enrollment Data Elements must be presented in both paper and electronic based EFT enrollment forms. Specifically, the rule requires that health plans (or their agents or vendors offering EFT) use the format, flow, and data set (including data element descriptions) as given in Table 4.2-1. Additionally, all CORE-required EFT Enrollment data elements (including DEGs) must appear in the same order as they appear in Table 4.2-1.

The CAQH CORE 380 Rule establishes a maximum set of data elements for both paper and electronic EFT enrollment. This maximum set of CORE-required EFT Enrollment Data Elements is specified in Table 4.2-1 of the rule. Section 4.3 and its subsections describe how the CORE-required Maximum EFT Enrollment Data Elements must be presented.

Also, the CAQH CORE 380 Rule does not preclude health plans (or their agents) from collecting additional data elements in locations beyond the EFT enrollment form for other purposes beyond EFT enrollment. Additionally, the CAQH CORE 380 Rule does not prohibit health plans and their agents from adding capabilities to the electronic EFT enrollment method designed to improve functionality and ensure data integrity and comprehensiveness. Examples of functional and data improvements that may be added to the electronic submission tool include:

• Use of drop-down selection lists and/or radio buttons to respond to each CORE-required Data Element or Sub-element
• Requiring re-entry of key data to ensure accuracy
• Inclusion of a context-specific “Help” button to display a window that provides a detailed description of the CORE-required Data Element or other guidance, e.g., data format, etc.
• Enabling the end user to assign nicknames to certain data fields to more easily manage his/her data
• Displaying all data entered to the end user for final review/correction prior to actual “submission”

Yes. The CAQH CORE 380: EFT Enrollment Data Rule and CAQH CORE 382: ERA Enrollment Data Rule establish a maximum set of data elements to be included on enrollment forms for EFT and ERA, as well as a required flow and format for presentation of the data elements on the form. The two rules were developed independent of each other as some health plans enroll providers separately for EFT and ERA while other combine the enrollments.

The CAQH CORE Enrollment Data Rules do not require or prohibit entities from creating a single form for the purposes of both EFT and ERA enrollment as long as the format, flow, and data set (including data element descriptions) are used as specified in CAQH CORE 380 Rule Table 4.2-1 and CAQH CORE 382 Rule Table 4.2-1. Sections 4.5 of the CAQH CORE 380 and 382 Rules specify the timeframe for converting existing paper-based EFT and ERA enrollment forms to comply with the rules.

Yes. The CAQH CORE 380 Rule establishes a maximum set of data elements to be included on an EFT enrollment form, as well as a required flow and format for presentation of the data elements on the form. The CAQH CORE 380 Rule does not require or prohibit entities from using an inclusive form for the purposes of EFT Enrollment as long as the format, flow, and data set (including data element descriptions) are used as given in CAQH CORE 380 Rule, Table 4.2-1, CORE-required Maximum EFT Enrollment Data Set. Section 4.5 of the CAQH CORE 380 Rule specifies the timeframe for converting existing paper-based enrollment forms to comply with the rule.

NOTE: Section 4.4 of the CAQH CORE 380 Rule also requires all health plans, and their agents or vendors offering EFT enrollment, to “implement and offer to any trading partner (e.g., a healthcare provider) an electronic method (actual method to be determined by health plan or its agent) and process for collecting the CORE-required Maximum EFT Enrollment Data Set.”

No. Per the CAQH CORE 380 Rule, Section 4.4, CORE Electronic Safe Harbor for EFT Enrollment to Occur Electronically, all health plans must “implement and offer to any trading partner (e.g., a healthcare provider) an electronic method (actual method to be determined by health plan or its agent) and process for collecting the CORE-required Maximum EFT Enrollment Data Set.”

Rule Section 4.4 also notes that the rule “DOES NOT require health plans or their agents to use ONLY an electronic method and process for collecting the CORE-required Maximum EFT Enrollment Data Set.” Health plans must offer an electronic method for collection and submission of the CORE-required Maximum EFT Enrollment Data Set, but they may continue to also offer a paper-based method of enrollment, provided that the paper-based method of enrollment also meets all applicable rule requirements (see especially Section 4.3.1, Master Template for Manual Paper-Based Enrollment).

No. Section 4.3.1 of the CAQH CORE 380 Rule requires that health plans provide instructions online for how providers can determine the status of the enrollment. The EFT enrollment form must include a section outlining how to access these online instructions. The CAQH CORE 380 Rule does not require that that the status of enrollment must be able to be determined via online tool.

The CORE-required Maximum EFT Enrollment Data Set includes eight Data Element Groups (DEGs). A DEG may be designated as required or optional for data collection. Additionally, within each DEG, Individual Data Elements may be designated as required or optional for data collection.

When a DEG is designated as required:

• The health plan must collect all Individual Data Elements within the DEG that are designated as required.
• The health plan may elect not to collect any Individual Data Elements within the DEG that are designated as optional.

When a DEG is designated as optional:

• The health plan may elect not to include this optional DEG for collection on the EFT Enrollment Form.
• However, if the health plan chooses to collect this optional DEG, the health plan must collect all Individual Data Elements within the DEG that are designated as required; the health plan may elect not to collect any Individual Data Elements within the optional DEG that are designated as optional.

No. If a health plan chooses to collect an optional DEG:

• The health plan must collect all Individual Data Elements within the optional DEG that are designated as required.
• However, the health plan may elect not to collect any Individual Data Elements within the optional DEG that are designated as optional.

Not collecting an Individual Data Element identified as optional is not prohibited by the CAQH CORE 380 Rule requirements for the CORE-required Maximum EFT Enrollment Data Set. However, the CAQH CORE 380 Rule requires that the following Individual Data Elements must be collected during the EFT Enrollment process:

• All required Individual Data Elements within required DEGs
• All Individual Data Elements designated as required within optional DEGs, if the health plan chooses to collect the optional DEG.

NOTE: The CAQH CORE 380 Rule does not prevent a health plan from pre- or auto-populating the form with known data (for the provider to confirm or change), but the required Individual Data Elements must still be collected during the process.

Section 4.4 of the CAQH CORE 380 Rule requires all health plans to offer an “electronic safe harbor” enrollment method/process for collecting the CORE-required Maximum EFT Enrollment Data Set. The CAQH CORE 380 Rule requires that the following Individual Data Elements must be included in the electronic enrollment method:

• All required Individual Data Elements within required DEGs
• All Individual Data Elements designated as required within optional DEGs, if the health plan chooses to collect the optional DEG.

No. The CAQH CORE 380 Rule, Section 4.3.2, Master Template for Electronic Enrollment, requires that a web-based method of enrollment is restricted “only to the extent that the flow, format and data set including data element descriptions established by this rule must be followed.” The CAQH CORE 380 Rule does not include any language surrounding pagination or other contiguity of the data. Therefore, a web-based enrollment method with data elements on different pages would be compliant with the rule requirements.

No. There is no XML Schema Specification (.xsd file) for the CAQH CORE EFT & ERA Operating Rules, including the CAQH CORE 380 Rule. However, to assist implementers, CAQH CORE has published Excel-based versions of both the CORE-required Maximum EFT Data Set and CORE-required Maximum ERA Enrollment Data Set tables. The Excel Workbooks are available at the links below and on the CAQH CORE website:

• Excel Copy of the CORE-required Maximum EFT Enrollment Data Set
• Excel Copy of the CORE-required Maximum ERA Enrollment Data Set

NOTE: CAQH CORE 380 Rule, Section 4.3.2, Master Template for Electronic Enrollment, does specify that: “When using an XML-based electronic approach, the Data Element Name and Sub-element Name must be used exactly as represented in the table enclosed in angle brackets (i.e., < >) for the standard XML element name and all spaces replaced with an underscore [ _ ] character e.g., <Provider_Address>.” There are no additional XML specifications for a web-based enrollment method beyond this requirement.

Yes. As noted above, CAQH CORE has published an Excel-based version of Table 4.2-1, CORE-required Maximum EFT Enrollment Data Set. The Excel Workbooks are available at the links below and on the CAQH CORE website:

• Excel Copy of the CORE-required Maximum EFT Enrollment Data Set
• Excel Copy of the CORE-required Maximum ERA Enrollment Data Set

Beyond this Excel document and the table in the CAQH CORE 380 Rule, there are no other available data file examples of the CORE-required Maximum EFT Enrollment Data Set.

No. The reference in the CAQH CORE 380 Rule to a “safe harbor” does not mean that health plans must support the CAQH CORE Connectivity Safe Harbor for collection of the CORE-required Maximum EFT Enrollment Data Set.

Section 4.4, CAQH CORE Electronic Safe Harbor for EFT Enrollment, of the CAQH CORE 380 Rule requires all health plans to offer an “electronic safe harbor” enrollment method/process for collecting the CORE-required Maximum EFT Enrollment Data Set. The CAQH CORE 380 Rule does not specify the electronic method that health plans must use to fulfill the safe harbor requirement.

While the CAQH CORE 380 Rule does not require health plans to do so, health plans may choose to use the CAQH CORE 270 Connectivity Safe Harbor to fulfill the CAQH CORE Electronic Enrollment Safe Harbor. The CAQH CORE Connectivity Rule is payload agnostic and thus can carry both X12 and non-X12 administrative transaction payloads. Section 4.4.4 of the CAQH CORE 270 Rule specifies how to enumerate non-X12 payloads in the PayloadType field.

No. The CAQH CORE 380 Rule establishes a maximum set of data elements for both paper and electronic EFT enrollment as well as how the CORE-required Maximum EFT Enrollment Data Elements must be presented in both paper and electronic based EFT enrollment forms The CAQH CORE 380 Rule does not establish a required timeframe for processing a provider’s EFT Enrollment.

NOTE: Section 4.2, CORE-required Maximum EFT Enrollment Data Elements, of the CAQH CORE 380 Rule requires the health plan to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements in Table 4.2-1.”

The CAQH CORE 380 Rule does not specify the exact wording for the instructions and guidance that must be provided by the health plan. In anticipation of provider questions, the health plan could choose to describe its expected timeframe for processing enrollments in these instructions.

Section 4.5 of the CAQH CORE 380 Rule specifies a time frame for health plans to convert all paper-based EFT enrollment forms relative to the compliance date for any Federal regulation that adopts the CAQH CORE 380 Rule for mandatory implementation. Specifically the rule states: “Not later than the date that is six months after the compliance date specified in any Federal regulation adopting this CORE Operating Rule, a health plan or its agent that uses a paper-based form to collect and submit the CORE-required Maximum EFT Enrollment Data Set must convert all its paper-based forms to comply with the data set specified in this rule.”

NOTE: The CAQH CORE 380 Rule requirement applies only if a health plan, or its agent or vendor offering EFT enrollment, has an existing paper-based enrollment form or chooses to use a paper-based form. The CAQH CORE 380 Rule does not require health plans to use a paper-based enrollment form if they do not currently do so. However, an electronic method for collecting and submitting the enrollment data elements is required.

In August 2012, HHS issued an Final Rule that adopts all of the CAQH CORE EFT & ERA Operating Rules to fulfill the Federal mandate under ACA Section 1104, with the exception of rule requirements pertaining to use of Acknowledgements. Per ACA Section 1104, the compliance date for the ACA-mandated EFT & ERA operating rules is January 1, 2014. Section 4.5 of the CAQH CORE 380 Rule requires health plans to modify their paper-based enrollment forms to conform to the CORE-required Maximum EFT Enrollment Data Set no later than six months after the January 1, 2014 Federal compliance date.

For more information on the ACA Section 1104 requirements for Federal operating rules, please see CAQH CORE FAQs Part B: ACA Section 1104 Mandate for Federal Operating Rules.

No. Verifying the accuracy of the data collected from the provider during the EFT enrollment process is out of scope for the CAQH CORE EFT & ERA Operating Rules. The policies and methods that a health plan uses to verify accuracy of data are business decisions on the part of the health plan or its agent or vendor offering EFT enrollment.

Data Element Group (DEG) 8: Submission Information in the CORE-required Maximum EFT Enrollment Data Set includes as an optional Individual Data Element “Include with Enrollment Submission”. This data element allows a health plan (or its agent or vendor offering EFT enrollment) to require providers to submit a voided check or bank letter for the purposes of authenticating the provider’s financial account. The CAQH CORE 380 Rule does not specify the method that health plans must use to obtain the check or bank letter. It is the health plan’s individual business decision what submission method it chooses to use to obtain the documentation from the provider.

Yes. A health plan (or its agent or vendor offering EFT enrollment) must collect all Individual Data Elements per the CAQH CORE 380 Rule requirements, including those for which the health plan has no business need.

The CORE-required Maximum EFT Enrollment Data Elements were identified after substantial industry research and analysis to compare EFT enrollment forms from across the industry. The CORE Participants agreed that these data elements represented the maximum set of data elements required for successful EFT enrollment. The CORE-required Maximum EFT Enrollment Data Set includes eight Data Element Groups (DEGs) designated as required or optional for data collection. Per Section 4.2, CORE-required Maximum EFT Enrollment Data Elements, of the CAQH CORE 380 Rule, the following Individual Data Elements must be included on either a paper-based or electronic enrollment form:

• All required Individual Data Elements within required DEGs
• All Individual Data Elements designated as required within optional DEGs, if the health plan chooses to collect the optional DEG.

No. Section 4.3.2, Master Template for Electronic Enrollment, of the CAQH CORE 380 Rule specifies that health plans “must use the CORE Master EFT Enrollment Data Element Name and Sub-element Name as specified in Table 4.2-1 without revision or modification.” As described in Section 3.2, CORE-required Maximum EFT Enrollment Data Element Set, this requirement serves to provide consistency across health plans’ enrollment processes and promotes provider adoption of EFT.

To meet the requirements specified in Section 4.3.2, the Data Element Name must be used in full on the electronic enrollment form. Use of an abbreviated Data Element Name on an electronic enrollment form does not satisfy the rule requirement.

Yes. Although a health plan (or its agent or vendor offering EFT enrollment) may not use a “mouse hover” function to provide the Data Element Names, the CAQH CORE 380 Rule does permit a health plan to use a “mouse hover” to display supplemental information about the enrollment data elements, such as the Data Element Description, or to provide further guidance to the provider on completing the enrollment form.

No. The CAQH CORE EFT & ERA Enrollment Data Rules (CAQH CORE 380 & 382 Rules) establish a maximum set of data elements to be included on an EFT and/or ERA enrollment form, as well as a required flow and format for presentation of the data elements on the form. The CAQH CORE EFT & ERA Enrollment Data Rules do not address whether or not health plans can make provider enrollment to receive healthcare EFT contingent on the provider also enrolling to receive the X12 v5010 835 ERA, or vice versa. Such a requirement is a health plan’s individual business decision.

Section 4.3 of the CAQH CORE 380 Rule requires health plans “to use the format, flow and data set including data element descriptions in Table 4.2-1 as the CORE Master EFT Enrollment Submission form” for both paper-based and electronic EFT enrollment methods. The intent of the reference to “format, flow, and data set” is:

• “Flow” means the order/sequence of the data elements in Table: 4.2-1
• “Data Set” is the set of elements specified in Table: 4.2-1
• “Format” refers to the Data Type and Format as specified in Table: 4.2-1 (e.g., alphanumeric, 15 characters for Zip Code).

CAQH CORE 380 Rule Table: 4.2-1 provides Data Element Descriptions and Data Types and Formats (when necessary) for the Individual Enrollment Data Elements in the CORE-required Maximum EFT Enrollment Data Set. Beyond the Data Element Descriptions and Data Types and Formats, further descriptive information (including citations) clarifying the terms used in Table 4.2-1 is provided via footnotes included for many of the Individual Data Elements. Beyond these references in the rule, there is not a separate glossary of terms.

The CAQH CORE 380 Rule does not define a specific format(s) that constitutes an electronic method and process for collecting the CORE-required Maximum EFT Enrollment Data Set.

CAQH CORE does not provide a definition of “electronic” methods specific to implementation of the CAQH CORE Operating Rules. Rather, CAQH CORE has relied on various HIPAA regulations to do so for the industry. Currently, there are many ways entities can implement an “electronic” collection method. In the broader context of the mission and vision of CAQH CORE, the goal is to assist the industry to adopt uniform and consistent automated electronic processes to reduce costs and build efficiencies.

CMS is the HHS designated authority on any decisions regarding interpretation, implementation, and enforcement of the regulations adopting the HIPAA and ACA Administrative Simplification standards and provisions. As the regulatory authority, the determination of what constitutes an “electronic” method for collecting the CORE-required Maximum EFT Enrollment Data Set must be made by the CMS National Standards Group (NSG). The January 2013 HHS HIPAA Privacy and Security omnibus final rule includes a definition of “electronic media,” and CAQH CORE has asked CMS NSG to provide further guidance to the industry on the regulatory language, and what constitutes an “electronic” method. It is anticipated that a CMS NSG FAQ will be published shortly; thereafter CAQH CORE will provide detailed examples of the multiple ways to meet the requirements for both electronic collection and submission.

The CAQH CORE Enrollment Data Rules do not prohibit entities from creating a single form for the purposes of both EFT and ERA enrollment. A combined EFT and ERA enrollment form must contain all of the required Data Element Groups (DEGs) and required Individual Data Elements from Table: 4.2-1, CORE-required Maximum EFT/ERA Enrollment Data Set, in CAQH CORE 380 Rule and CAQH CORE 382 Rule. NOTE: Entities are not required to repeat DEGs that are identical in both enrollment data rules (e.g., DEG1).

Although the CAQH CORE Enrollment Data Rules do not explicitly outline the flow and format for a combined EFT and ERA enrollment form, DEGs unique to either of the CAQH CORE Enrollment Data Rules would need to be collected using the same general flow and format. For example, “Financial Institution Information” (DEG7 in the CAQH CORE 380 Rule) and “Electronic Remittance Advice Information” (DEG7 in the CAQH CORE 382 Rule) are both required for collection on a combined EFT and ERA enrollment form. Both DEGs would be collected after DEGs 1 through 6 in the CAQH CORE 380 and CAQH CORE 382 Rules, and before “Submission Information”, DEG 10 in the CAQH CORE 382 Rule.

No. The CAQH CORE EFT & ERA Operating Rules do not specify timeframe requirements regarding how soon a health plan must process a provider’s EFT and/or ERA enrollment and/or implement a connection with the provider to deliver the transactions.

However, the CAQH CORE EFT & ERA Operating Rules do specify timeframe requirements that address exchange of the NACHA CCD+ and X12 v5010 835 transactions such as:

• CAQH CORE 350: Health Care Claim Payment/Advice (835) Rule: Section 4.3, Dual Delivery of v5010 X12 835 and Proprietary Paper Claim Remittance Advices, requires health plans to support a dual or parallel processing period during which providers can continue to receive proprietary paper RAs while they test the use of the X12 v5010 835 standard and associated operating rules. The dual delivery period must be a period of 31 days or a minimum of 3 payments, whichever is longer.
  • NOTE: The dual delivery requirement applies only if the health plan currently delivers proprietary paper RAs. If a health plan does not currently deliver proprietary paper RAs, the CAQH CORE 350 Rule does not require a health plan to start doing so.
• CAQH CORE 370: EFT & ERA Reassociation (CCD+/835) Rule: Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transactions, requires health plans to release the X12 v5010 835: “No sooner than three business days based on the time zone of the health plan prior to the CCD+ Effective Entry Date And No later than three business days after the CCD+ Effective Entry Date.”
  • The elapsed time requirement means that a health plan must not send the corresponding X12 v5010 835 earlier than three business days prior to the CCD+ Effective Entry Date or later than three business days after the CCD+ Effective Entry Date.

The CAQH CORE 380 Rule does not define a specific format(s) that constitutes an electronic method and process for submitting the CORE-required Maximum EFT Enrollment Data Set.

CAQH CORE does not provide a definition of “electronic” methods specific to implementation of the CAQH CORE Operating Rules. Rather, CAQH CORE has relied on various HIPAA regulations to do so for the industry. Currently, there are many ways entities can implement “electronic” methods for data submission. In the broader context of the mission and vision of CAQH CORE, the goal is to assist the industry to adopt uniform and consistent automated electronic processes to reduce costs and build efficiencies.

CMS is the HHS designated authority on any decisions regarding interpretation, implementation, and enforcement of the regulations adopting the HIPAA and ACA Administrative Simplification standards and provisions. As the regulatory authority, the determination of what constitutes an “electronic” method for submitting the CORE-required Maximum EFT Enrollment Data Set must be made by the CMS National Standards Group (NSG). The January 2013 HHS HIPAA Privacy and Security omnibus final rule includes a definition of “electronic media,” and CAQH CORE has asked CMS NSG to provide further guidance to the industry on the regulatory language, and what constitutes an “electronic” method. It is anticipated that a CMS NSG FAQ will be published shortly; thereafter CAQH CORE will provide detailed examples of the multiple ways to meet the requirements for both electronic collection and submission.

No. The CAQH CORE 380 Rule does not explicitly define what a health plan must collect for the Sub-element “Email Address” when a provider does not have an email address. However, Section 4.2, CORE-required Maximum EFT Enrollment Data Elements requires a health plan to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements in Table 4.2-1.” The health plan could, in these instructions, describe what the provider should enter in the event that the provider does not have an email address (e.g., “If you do not have an email address, please leave the field blank,” or “If you do not have an email address, please enter ‘NONE’,” etc.)

Yes. The CAQH CORE 380 Rule provides a uniform and consistent maximum set of data elements that can be used by any health plan (or its agent/vendor offering EFT enrollment) for the purposes of enrolling any healthcare provider to receive claim payment electronically. This data set is the same for all providers and all health plans (or their agents/vendors); the CAQH CORE 380 Rule, therefore, can support approaches that are designed to enroll all providers with all plans (i.e., mass enrollment).

Section 4.2 of the CAQH CORE 380 Rule requires a health plan (or its agent/vendor offering EFT enrollment) to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements”. A clearinghouse, or other intermediary, could include in these instructions guidance specific to the health plans for which it is authorized to collect enrollment data.

The CAQH CORE 380 Rule does not address the functionality or capability of an EFT enrollment system or process, which may include other data functions/capabilities beyond the collection of the CORE-required Maximum EFT Enrollment Data Set. A clearinghouse, or other intermediary, that conducts mass enrollment may include data fields in its enrollment process to collect information such as with which health plans providers want to enroll (specific to the health plans for which the clearinghouse is authorized to collect such provider enrollment data). Such a data field could be included in the enrollment process prior to or after collection of the CORE-required Maximum EFT Enrollment Data Set.

The CAQH CORE 380 Rule also permits clearinghouses, and other entities conducting EFT enrollment, to include other functionalities in the enrollment process (e.g., requiring a username/password to log on to the health plan’s website to begin the enrollment process, use of a mouse hover to display supplemental information about data elements, etc.). For further guidance, see “Can additional data elements beyond the CORE-required Maximum EFT Enrollment Data Elements be collected for EFT enrollment?”)

Section 4.3.1, Master Template for Manual Paper-Based Enrollment, of the CAQH CORE 380 Rule requires that a health plan (or its agent/vendor offering EFT enrollment) “use the format, flow and data set including data element descriptions in Table 4.2-1 as the CORE Master EFT Enrollment Submission form when using a manual paper-based enrollment method.” The CAQH CORE 380 Rule does not require that the Data Element Descriptions be included directly next to the Individual Data Element Name on the paper-based form. A health plan may include the Data Element Descriptions in an Appendix to the paper-based enrollment form provided that the health plan, as required by Section 4.3.1, “clearly label[s] any appendix describing its purpose as it relates to the provider enrolling in EFT.”

NOTE: The CAQH CORE 380 Rule does not require health plans to use a paper-based enrollment form if they do not currently do so. However, an electronic method for collecting and submitting the enrollment data elements is required. As with the paper-based form, the Data Element Descriptions are not required to be included directly next to the Individual Data Element Name on the electronic enrollment form. Health plans may use a function such as a “mouse hover” to display the Data Element Descriptions. (See FAQ “As a health plan, do I conform to the CAQH CORE 380 Rule requirements for presentation of the CORE-required EFT Enrollment Data Elements if I use a “mouse hover” function to provide the descriptions of the enrollment data elements?”)

Per the HIPAA Administrative Simplification provisions, as of May 2008, HIPAA covered entities must use the National Provider Identifier (NPI) only to identify a group or individual as a HIPAA covered provider in the HIPAA transaction standards. A Taxpayer Identification Number (TIN), e.g., Social Security Number (SSN) or Employer Identification Number (EIN), can only be used when identifying a HIPAA covered provider as a tax payer.

These requirements do not apply to providers that are not HIPAA-covered as non-HIPAA covered providers are not required to obtain and use an NPI. Per CMS, a non-HIPAA covered provider that does not have an NPI should be identified in the HIPAA transaction standards by “its SSN or EIN as its Primary Identifier in standard transactions designed to capture a Primary and a Secondary Identifier for a health care provider [or] by one of the qualifiers (other than the qualifier for the NPI) listed in the Implementation Guides that are designed to capture a single identifier for a health care provider” (see CMS FAQ#1949).

The CAQH CORE 380 Rule requires inclusion of both NPI and TIN as “Provider Identifier” and “Account Number Linkage to Provider Identifier” sub-elements to allow for enrollment of a non-HIPAA covered provider that does not have an NPI.

Data Element Groups (DEGs) 2 and 7 represent two different sets of data elements that are necessary to enroll a provider to receive claim payments via EFT:

• DEG2: Provider Identifiers Information collects information related to the enrolling provider identified in DEG1: Provider Information. Within DEG2, health plans (or their agent/vendor offering EFT enrollment) are required to collect a “Provider Identifier” which must be the identification number, NPI or TIN for non-HIPAA covered providers, for the legal entity reported under the “Provider Name” Data Element in DEG1.
• DEG7: Financial Institution Information collects information related to the Receiving Depository Financial Institution (RDFI) where the provider maintains the account to which claim payments are to be deposited. Within DEG7, health plans (or their agent/vendor offering EFT enrollment) are required to collect an “Account Number Linkage to Provider Identifier”, which must be the identification number, NPI or TIN for non-HIPAA covered providers, linked to the provider’s RDFI account.

The identification number linked to the provider’s RDFI account may differ from the identification number used to identify the legal entity. As such, the CAQH CORE 380 Rule requires health plans (or their agent/vendor offering EFT enrollment) to collect an identification number in both DEG2 and DEG7.

No. While the identifier collected for DEG2: Provider Identifiers Information can be the same as the identifier collected for DEG7: Financial Institution Information, the CAQH CORE 380 Rule does not require them to be the same.

Data Element Groups (DEGs) 2 and 7 represent two different sets of data elements that are necessary to enroll a provider to receive claim payments via EFT:

• DEG2: Provider Identifiers Information collects information related to the enrolling provider identified in DEG1: Provider Information. Within DEG2, health plans (or their agent/vendor offering ERA enrollment) are required to collect a “Provider Identifier”, which must be the identification number, NPI or TIN for non-HIPAA covered providers, for the legal entity reported under the “Provider Name” Data Element in DEG1: Provider Information.
• DEG7: Financial Institution Information collects information related to the Receiving Depository Financial Institution (RDFI) where the provider maintains the account to which claim payments are to be deposited. Within DEG7, health plans (or their agent/vendor offering ERA enrollment) are required to collect an “Account Number Linkage to Provider Identifier” which must be the identification number, NPI or TIN for non-HIPAA covered providers, linked to the provider’s RDFI account.

Depending on how a provider has established its financial accounting structure, the provider’s RDFI account could be linked to an identification number that is different from the identification number used to identify the legal entity being enrolled for EFT. As shown in the figure below, a number of arrangements may exist:

• A provider, individual or group, can have a single TIN that is linked to both a single NPI and a single RDFI account.
• A provider group can have a single TIN that is linked to multiple NPIs, representing both individual provider subparts and the provider entity as a whole, with each NPI linked to a different RDFI account.
• A provider individual can have a single NPI that is linked to multiple TINs, representing different provider organizations, and a single RDFI account.

As the identification number linked to the provider’s RDFI account may differ from the identification number used to identify the legal entity, the CAQH CORE 380 Rule does not require the identification numbers collected within DEG2 and DEG7 to be the same.

Please note: As the X12 v5010 835 TR3 requires a single X12 v0510 835 to correspond to a single EFT payment, the CAQH CORE 380 Rule does require the identifier collected for “Account Number Linkage to Provider Identifier” during EFT enrollment to be the same as the identifier collected for “Preference for Aggregation of Remittance Data” during ERA enrollment (see CAQH CORE 382: ERA Enrollment Data Rule).

The CAQH CORE 380 Rule includes the following requirements for collection of National Provider Identifier (NPI) and Taxpayer Identification Number (TIN) within the CORE-required Maximum EFT Enrollment Data Set:

• DEG2: Provider Identifiers Information collects information related to the enrolling provider identified in DEG1: Provider Information. DEG2 requires health plans (or their agent/vendor offering EFT enrollment) to collect a “Provider Identifier” which must be the identification number, NPI or TIN for non-HIPAA covered providers, for the legal entity reported under the “Provider Name” Data Element in DEG1: Provider Information.
• DEG7: Financial Institution Information collects information related to the Receiving Depository Financial Institution (RDFI) where the provider maintains the account to which claim payments are to be deposited. DEG7 requires health plans (or their agent/vendor offering EFT enrollment) to collect an “Account Number Linkage to Provider Identifier” which must be the identification number, NPI or TIN for non-HIPAA covered providers, linked to the provider’s RDFI account.

The CAQH CORE 380 Rule addresses the data to be collected during EFT enrollment; it does not specify requirements for health plans to implement a certain process after the data is collected. Beyond the data collection requirements, how a health plan groups claim payments to providers is a business decision and contract issue to be negotiated between the health plan and its provider trading partners.

Section 4.2 of the CAQH CORE 380 Rule requires health plans to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements”. The health plan could include in these instructions a description of its entity-specific process to reach agreement on payment grouping.

Yes. The CAQH CORE 380 Rule provides a uniform and consistent maximum set of data elements that can be used by any health plan (or its agent or vendor) for the purposes of enrolling any healthcare provider (or its agent) to receive claim payment via EFT. This maximum set of data elements is specified in Table 4.2-1 of the CAQH CORE 380 Rule, organized by categories of information referred to as “Data Element Groups” (DEGs).

As part of DEG2: Provider Identifiers Information (DEG2), a health plan (or its agent or vendor offering EFT enrollment) can choose to collect an optional Other Identifier(s). The Other Identifier(s) Individual Data Element allows a health plan to collect proprietary provider identifiers specific to its individual business needs. The CAQH CORE 380 Rule does not specify a data type or format for this identifier. Therefore, a health plan can use the Optional Identifier(s) data element to collect identification numbers for all service locations for which the enrolling provider wants to receive EFT.

Section 4.2, CORE-required Maximum EFT Enrollment Data Elements, in the CAQH CORE 380 Rule requires a health plan to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements in Table 4.2-1.” A health plan can include guidance in these instructions for how providers should complete the Other Identifier(s) data element.

The CAQH CORE 380 Rule also permits health plans, and their agents or vendors offering EFT enrollment, to include other functionalities in the enrollment process improve functionality and ensure data integrity and comprehensiveness. For example, a health plan may use a drop down list to identify the optional service locations (via their proprietary identifiers) for which the providers can enroll to receive EFT. For further guidance, see “Can additional data elements beyond the CORE-required Maximum EFT Enrollment Data Elements be collected for EFT enrollment?”)

As specified in Section 3.1, When the Rule Applies, the CAQH CORE 380 applies “when a health plan or its agent is enrolling a healthcare provider (or its agent)” to receive claim payment electronically via the Healthcare EFT Standards. As referenced, a “provider agent” is an entity that that has been designated and sufficiently authorized by the provider to receive EFT payments on the provider’s behalf. DEG4: Provider Agent Information in the CORE-required Maximum EFT Enrollment Data Set enables a health plan (or its agent/vendor offering EFT enrollment) to collect information about the provider’s designated agent.

No. The CAQH CORE 380 Rule does not require a health plan, or its agent/vendor offering EFT enrollment, to include the DEG number on its electronic or paper-based EFT enrollment form/method. NOTE: Use of paper-based method is optional.

Section 4.3, CORE Master Template for Collecting EFT Enrollment Data, of the CAQH CORE 380 Rule requires health plans “to use the format, flow and data set including data element descriptions in Table 4.2-1 as the CORE Master EFT Enrollment Submission form” for both paper-based and electronic EFT enrollment methods. To conform to the flow, format, and data content requirements, a health plan, or its agent/vendor offering EFT enrollment, must include the data element name and data element description, without revision or modification, on its EFT enrollment form/method and follow the order/sequence as given in Table: 4.2-1.

NOTE: The CAQH CORE 380 Rule does not require health plans to offer a paper-based enrollment form. However, an electronic method for collection and submission of the CORE-required Maximum EFT Enrollment Data Set must be offered. If a health plan chooses to also offer a paper-based enrollment form it must conform to all applicable CAQH CORE 380 Rule requirements.

No. The CAQH CORE 380 Rule does not require a health plan, or its agent/vendor offering EFT enrollment, to include the column header labels in Table 4.2-1 (e.g., “Individual Data Element”, “Sub-Element name”, “Data Element Description”, “Data Element Requirement for Health Plan Collection”, etc.) on its electronic or paper-based EFT enrollment form/method. NOTE: Use of a paper-based method is optional.

Section 4.3, CORE Master Template for Collecting EFT Enrollment Data, of the CAQH CORE 380 Rule requires health plans “to use the format, flow and data set including data element descriptions in Table 4.2-1 as the CORE Master EFT Enrollment Submission form” for both paper-based and electronic EFT enrollment methods. To conform to the flow, format, and data content requirements, a health plan, or its agent/vendor offering EFT enrollment, must include the data element name and data element description, without revision or modification, on its EFT enrollment form/method and follow the order/sequence as given in Table 4.2-1.

NOTE: The CAQH CORE 380 Rule does not require health plans to offer a paper-based enrollment form. However, an electronic method for collection and submission of the CORE-required Maximum EFT Enrollment Data Set must be offered. If a health plan chooses to also offer a paper-based enrollment form it must conform to all applicable CAQH CORE 380 Rule requirements.

No. Section 4.3.1, Master Template for Manual Paper-Based Enrollment, of the CAQH CORE 380 Rule requires a health plan (or its agent/vendor offering EFT enrollment) to include the following items on its paper-based EFT enrollment form:

• Specific written instructions and guidance for completing and submitting the enrollment form
• A number to fax and/or a U.S. Postal Service or email address to send the completed form
• Contact information for the health plan, specifically a telephone number and/or email address to send questions
• Authorization language for the provider to read and consider
• A section that outlines how the provider can access online instructions for how to determine the status of the EFT enrollment
• Clear labels for any appendix describing its purpose as it relates to the provider enrolling in EFT
• Information that the provider must contact its financial institution to arrange for the delivery of the CORE-required Minimum CCD+ data elements needed for reassociation of the payment and the ERA.

The CAQH CORE 382 Rule does not specify any requirements regarding pagination. A health plan may choose to include the above additional items on a single page of the enrollment form or on a separate page at the health plan’s discretion. NOTE: To conform to the flow and format requirements specified in Section 4.3 of the CAQH CORE 380 Rule, the above items cannot appear within or between the Maximum Enrollment Data Elements.

NOTE: The CAQH CORE 380 Rule does not require health plans to offer a paper-based enrollment form. However, an electronic method for collection and submission of the CORE-required Maximum EFT Enrollment Data Set must be offered. If a health plan chooses to also offer a paper-based enrollment form it must conform to all applicable CAQH CORE 380 Rule requirements.

Data Element Group (DEG) 8: Submission Information in the CORE-required Maximum EFT Enrollment Data Set includes as a required Individual Data Element “Authorized Signature”. This data element allows a health plan (or its agent/vendor offering EFT enrollment) to collect the “signature of an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment”. As specified in Table: 4.2-1, a health plan (or its agent/vendor offering EFT enrollment) can require this signature to be submitted either electronically or written (i.e., “wet”). It is the health plan’s individual business decision what method it chooses to use to obtain the authorizing signature.

Section 4.2 in the CAQH CORE 380 Rule requires a health plan to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements in Table 4.2-1.” Depending on what method the health plan chooses to obtain the authorized signature, the health plan could provide guidance to the provider in the instructions for how providers should submit the signature (e.g., if the health plan chooses to include “Written Signature of Person Submitting Enrollment” in its electronic enrollment method, the health plan could instruct the provider how to deliver the required wet signature prior to/along with/after completion of the electronic enrollment in EFT).

As specified in Section 3.4, CORE Process for Maintaining CORE-required Maximum EFT Enrollment Data Set, of the Phase III CAQH CORE 380: EFT Enrollment Data Rule and Phase III CAQH CORE 382 ERA Enrollment Data Rule, the CAQH CORE-required Maximum EFT & ERA Enrollment Data Sets are reviewed and updated on an annual basis. Section 3.4 in the CAQH CORE 380 and CAQH CORE 382 Rules requires that the first review of the enrollment data sets commence one year after the rules were adopted into federal regulation. This first review occurred in 2014.

• Limited Reviews: Occur biennially and consider only non-substantive adjustments to the Enrollment Data Sets; occur on an alternating schedule with Comprehensive Reviews (next Limited Review is in 2016)
• Comprehensive Reviews: Occur biennially and consider both substantive and non-substantive adjustments to the Enrollment Data Sets; occur on an alternating schedule with Limited Reviews (next Comprehensive Review is in 2017)

NOTE: Adjustments pertaining to rule language and requirements beyond the CAQH CORE-required Maximum EFT & ERA Enrollment Data Sets are out of scope for the CAQH CORE EFT & ERA Enrollment Data Maintenance Process.

In keeping with the CAQH CORE multi-stakeholder, collaborative and transparent rule development process, participation in the CAQH CORE Enrollment Data Task Group is open to representatives from any CORE Participating Organization. There is no limit to the number of representatives that a CORE Participating Organization can assign to the Task Group. Individuals with knowledge of the business processes and work flows for EFT and ERA enrollments are strongly encouraged to join the Task Group. Interested participants can send their name, title, organization name, email address, and telephone number to core@caqh.org.

Per the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, the CAQH CORE Enrollment Data Task Group conducts two types of review of the CAQH CORE-required Maximum EFT & ERA Enrollment Data Sets:

• Comprehensive Reviews consider both potential substantive and non-substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets.
• Limited Reviews consider potential non-substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets.

Comprehensive and Limited Reviews occur biennially on alternating years; i.e., if a Comprehensive Review occurs one year, a Limited Review will occur the following year.

As defined in the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, substantive adjustments address addition of new data elements/Data Element Groups (DEGs) to address emerging, new, or changing industry needs. Non-substantive adjustments improve usability of the enrollment data set but do not change the name, position, or collection requirements for the CORE-required EFT & ERA Enrollment data elements, sub-elements, or DEGs.

Once the CAQH CORE Enrollment Data Task Group approves a set of substantive and/or non-substantive adjustments to the CAQH CORE EFT & ERA Enrollment Data Sets, updated CAQH CORE EFT & ERA Enrollment Data Rules will be published. HIPAA-covered entities will need to update their EFT and ERA enrollment forms/systems to ensure conformance with any substantive adjustments applied to the data sets as a result of a Comprehensive Review. NOTE: HIPAA-covered entities will not need to update their EFT and ERA enrollment forms/systems as a result of a Limited Review.

2014 Review

In Q2 2014, the CAQH CORE Enrollment Data Task Group conducted the first Limited Review of the CORE-required Maximum EFT & ERA Enrollment Data Sets.

In this Limited Review, Task Group members identified and addressed non-substantive adjustments in the CORE-required Maximum EFT & ERA Enrollment Data Sets to improve implementer usability of the Enrollment Data Sets, including formatting inconsistencies and typographical errors, consistency between data elements, and improving clarity on data elements that generated questions from implementers. These non-substantive updates did not require HIPAA-covered entities to update their enrollment forms/systems.

Versions 3.0.1 of the Phase III CAQH CORE 380: EFT Enrollment Data Rule and Phase III CAQH CORE 382: ERA Enrollment Data Rule were distributed to the industry in September 2014.

2015 Review

The CAQH CORE Enrollment Data Task Group convened in Q4 2015 to conduct its first scheduled Comprehensive Review of the CORE-required Maximum EFT & ERA Enrollment Data Sets. During the Task Group's 2015 Review, Task Group members reviewed the rationale for and against conducting a Comprehensive Review. Upon consideration, the Task Group elected NOT to conduct a Comprehensive Review. This decision was based on several factors, which included:

• Industry resources better spent on higher-priority items such as ICD-10, completing implementations of mandated operating rules, and preparing for Phase IV CAQH CORE Operating Rules implementation
• Lack of an industry-wide call to action for adjustments to the Enrollment Data Sets, i.e. CAQH CORE did not receive any Requests related to the Data Sets in 2015
• Current Data Sets are successfully implemented in the market, i.e. more than 30 organizations are Phase III CORE-certified and in conformance with the Data Sets

Additionally, the Task Group sought to collect non-substantive adjustments as part of a Limited Review. As no non-substantive adjustments were proposed, the Task Group did not update the Enrollment Data Sets in 2015. 

The next Comprehensive Review of the CORE-required Maximum EFT & ERA Enrollment Data Sets is schedule to occur in 2017. Per the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, the Comprehensive Reviews consider both substantive and non-substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets. More information on the 2017 Comprehensive Review will be shared later in 2017.

The CAQH CORE Enrollment Data Task Group uses a set of Enrollment Data Evaluation Criteria to evaluate potential substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets. When submitting potential substantive adjustments for Task Group consideration, stakeholder entities will be required to confirm that their submission meets at least four of the seven criteria listed below:

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
2. 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
3. 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
4. Meets a demonstrated, new or current industry-wide multi-stakeholder business need not addressed by the existing Enrollment Data Set
5. Ensures collection of key items needed to fully automate both claims payment and remittance advice posting processes
6. 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
7. Consistent with Phase III CAQH CORE Guiding Principles

In addition to alignment with the above Evaluation Criteria, the Enrollment Data Task Group’s policy is to collect Supporting Information including a Business Case and any applicable Supporting Data for each submitted potential substantive adjustment to the CORE-required Maximum EFT & ERA Enrollment Data Sets.

For more information on the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, see the CAQH CORE EFT & ERA Enrollment Data Set Maintenance Process webpage.

Once the CAQH CORE Enrollment Data Task Group approves a set of substantive and/or non-substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets, an updated version of the CAQH CORE EFT & ERA Enrollment Data Rules will be published. Publication of updated versions of the CAQH CORE EFT & ERA Enrollment Data Rules will be announced on the CAQH CORE webpage and via an industry-wide email notification.

HIPAA-covered entities will need to update their EFT and ERA enrollment forms/systems to ensure conformance with any substantive adjustments applied to the data sets as a result of a Comprehensive Review. Per the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, a health plan, or its agent offering EFT and/or ERA enrollment, will have:

• NINE calendar months to update their electronic EFT and/or ERA enrollment systems or forms and
• TWELVE calendar months to update their paper-based EFT and/or ERA enrollment forms.

The compliance timeframe for HIPAA-covered entities to adjust their systems and/or forms begins on the date of publication of the updated versions of the CORE-required Maximum EFT & ERA Enrollment Data Sets.

Per the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, Comprehensive and Limited Reviews of the CORE-required Maximum EFT & ERA Enrollment Data Sets occur biennially on alternating years (i.e., if a Comprehensive Review occurs one year, a Limited Review will occur the following year). The 2016 Review is scheduled to be a Limited Review followed by a Comprehensive Review in 2017.

Entities are encouraged to join CAQH CORE as a CORE Participating Organization to contribute to the evolution of the CORE-required Maximum EFT & ERA Enrollment Data Sets via the CAQH CORE Enrollment Data Task Group. Participation in CAQH CORE also enables industry entities to have a say in the development of operating rules, and be part of a solution that diminishes the cost and complexity within the healthcare system. CAQH CORE welcomes Participating Organizations representing a range of stakeholder groups.

The CAQH CORE EFT & ERA Enrollment Data Sets Task Group is open to representatives from any CORE Participating Organization. There is no limit to the number of representatives that a CORE Participating Organization can assign to the Task Group. Individuals with knowledge of the business processes and work flows for EFT and ERA enrollments are strongly encouraged to join the Task Group. Interested participants can send their name, title, organization name, email address, and telephone number to core@caqh.org.

Entities can also contribute a number of other ways, including attendance on bimonthly CAQH CORE Town Hall Calls. Interested entities should email core@caqh.org for further information.

The CORE-required Maximum EFT Enrollment Data Set includes eight Data Element Groups (DEGs). For each DEG, Table 4.2-1, CORE-required Maximum EFT Enrollment Data Set, specifies whether the DEG is “required” or “optional” for data collection. Additionally, within each DEG, Individual Data Elements or Sub-elements may be designated as “required” or “optional” for data collection. This designation is provided in the “Data Element Requirement for Health Plan Collection” column in Table 4.2-1.

The “required” or “optional” designation identified in Table 4.2-1 is specific to whether a health plan, or its agent, must include the DEG or Individual Date Element/Sub-element on its EFT enrollment form/method. The CAQH CORE 380 Rule does not address requirements for provider completion of the elements included on the EFT enrollment form/method. As such, if a health plan chooses to include an “optional” Individual Data Element or Sub-element on its EFT enrollment method, it is permitted by the CAQH CORE 380 Rule to make completion of this “optional” data element mandatory for enrolling providers.