Frequently Asked Questions - VI. CAQH CORE Payment & Remittance EFT Enrollment Data Rule

No. The CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0, 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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. To comply with the CAQH CORE Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data Rule vPR.1.0 establishes a maximum set of data elements for both paper and electronic EFT enrollment. This maximum set of CORE-required EFT Enrollment Data Elements 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data 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 better manage his/her data
• Displaying all data entered to the end user for final review/correction prior to actual “submission”

No. Per the CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0, Section 4.4, CAQH 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. The CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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 Payment & Remittance EFT Enrollment Data Rule does not require that that the status of enrollment must be able to be determined via online tool.

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 Payment & Remittance EFT Enrollment Data Rule vPR.1.0 requirements for the CORE-required Maximum EFT Enrollment Data Set. However, the CAQH CORE Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data Rule does not prevent a health plan from pre-populating, 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.

No. The reference in the CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 to a “safe harbor” does not mean that health plans must support the CAQH CORE Connectivity Safe Harbor in the CAQH CORE Connectivity Rule vC2.2.0 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data Rule does not specify the electronic method that health plans must use to fulfill the safe harbor requirement.

While the CAQH CORE Payment & Remittance EFT Enrollment Data Rule does not require health plans to do so, health plans may choose to use the CAQH CORE Connectivity Safe Harbor in the CAQH CORE Connectivity Rule vC2.2.0 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 Connectivity Rule vC2.2.0 specifies how to enumerate non-X12 payloads in the PayloadType field.

No. The CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance 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 Payment & Remittance EFT Enrollment Data 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.

No. Verifying the accuracy of the data collected from the provider during the EFT enrollment process is out of scope for the CAQH CORE Payment & Remittance 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 Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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.

Section 4.3 of the CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 requires health plans “to use the format, flow and data set including data element descriptions in 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).

The CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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 Division of National Standards (DNS). The January 2013 HHS HIPAA Privacy and Security omnibus final rule includes a definition of “electronic media,” and CAQH CORE has asked CMS DNS to provide further guidance to the industry on the regulatory language, and what constitutes an “electronic” method.

The CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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 if 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 Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data 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.).

The CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data Rule also 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 Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data 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, CAQH CORE-required Maximum EFT Enrollment Data Elements, in the CAQH CORE Payment & Remittance EFT Enrollment Data 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.” A health plan can include guidance in these instructions for how providers should complete the Other Identifier(s) data element.

The CAQH CORE Payment & Remittance EFT Enrollment Data 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.

As specified in Section 3.1, When the Rule Applies, the CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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 Master Template for Manual Paper-Based Enrollment of the CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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 Payment & Remittance ERA Enrollment Data 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 Payment & Remittance EFT Enrollment Data Rule, the above items cannot appear within or between the Maximum Enrollment Data Elements.

NOTE: The CAQH CORE Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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).

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.

The CORE-required Maximum EFT Enrollment Data Set includes eight Data Element Groups (DEGs). For each DEG, the CAQH 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.”

The “required” or “optional” designation identified 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 Payment & Remittance EFT Enrollment Data 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 rules to make completion of this “optional” data element mandatory for enrolling providers.