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

No. The CAQH CORE Payment & Remittance EFT Enrollment Data 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 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.

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 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.

Not collecting an Individual Data Element identified as optional is not prohibited by the CAQH CORE Payment & Remittance EFT Enrollment Data Rule 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.

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.

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.

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.

No. Section 4.3.2, Master Template for Electronic Enrollment, of the CAQH CORE Payment & Remittance EFT Enrollment Data 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.

No. The CAQH CORE Payment & Remittance EFT Enrollment Data Rule and CAQH CORE Payment & Remittance ERA Enrollment Data Rule 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 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.

The CAQH CORE Payment & Remittance EFT Enrollment Data 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 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.

No. The Master Template for Manual Paper-Based Enrollment of the CAQH CORE Payment & Remittance EFT Enrollment Data 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 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 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.

Yes. The CAQH CORE Payment & Remittance EFT Enrollment Data Rule and CAQH CORE Payment & Remittance 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 Payment & Remittance EFT & ERA Enrollment Data Rule Tables 4.2-1. Sections 4.5 of the EFT & ERA Enrollment Data Rules specify the timeframe for converting existing paper-based EFT and ERA enrollment forms to comply with the rules.

Yes. The CAQH CORE Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Rule, Table 4.2-1, CORE-required Maximum EFT Enrollment Data Set. Section 4.5 of the CAQH CORE Payment & Remittance EFT Enrollment Data Rule specifies the timeframe for converting existing paper-based enrollment forms to comply with the rule.

Note: Section 4.4 of the CAQH CORE Payment & Remittance EFT Enrollment Data 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.”

Section 4.4 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 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 Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data 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.

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

Yes. A health plan (or its agent or vendor offering EFT enrollment) must collect all Individual Data Elements per the CAQH CORE Payment & Remittance EFT Enrollment Data 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) designatedas required or optional for data collection. Per Section 4.2, CORE-required Maximum EFT Enrollment Data Elements, of the CAQH CORE Payment & Remittance EFT Enrollment Data 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.

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 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 Payment & Remittance EFT and ERA Enrollment Data Rules. 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 Payment & Remittance EFT Enrollment Data Rule) and “Electronic Remittance Advice Information” (DEG7 in the CAQH CORE Payment & Remittance ERA Enrollment Data 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 Payment & Remittance Enrollment Data Rules, and before “Submission Information”, DEG 10 in the CAQH CORE Payment & Remittance ERA Enrollment Data Rule.

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 listed in the Implementation Guides to capture a single identifier for a health care provider.

The CAQH CORE Payment & Remittance EFT Enrollment Data 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.

The CAQH CORE Payment & Remittance Operating Rules support the healthcare industry's transition to electronic payment and remittance advice. Two of the five CAQH CORE Payment & Remittance Operating Rules address the barriers to greater provider EFT and/or ERA enrollment due to the variance in the required processes and data elements. The EFT & ERA Enrollment Data Rules address these variances by outlining maximum sets of standard data elements (e.g., the CORE-required Maximum EFT & ERA Enrollment Data Sets) to be collected by a health plan or its agent during provider enrollment in EFT and/or ERA. The rules also outline a flow and format for electronic collection of the data elements (and paper-based forms if offered) among other requirements.

The EFT & ERA Enrollment Data Rules also recognize the need for ongoing maintenance of the CORE-required Maximum EFT & ERA Enrollment Data Sets and requires establishment of a policy and process to review the Enrollment Data Sets no less than annually. From 2014 - 2020, review of the Enrollment Data Sets was conducted annually, with limited in-scope submissions from the industry and no substantive adjustments to the data sets.

As such, CAQH CORE Participants elected to transition the EFT/ERA Enrollment Data Maintenance Process to an ongoing, "rolling submission" process whereby adjustments can be submitted at any point in time rather than only during the annual review periods. The updated process allows industry to review the data sets on a continuous basis, in accordance with Section 3.4 CAQH CORE Process for Maintaining CORE-Required Maximum EFT/ERA Enrollment Data Sets. CAQH CORE will publicly track all submission on this webpage for transparency.

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.

The EFT Enrollment Data Set does not define the field length for “Street.” During initial rule development, CAQH CORE Participants purposefully maintained flexibility with this field given the potential for updates to address formats from USPS.

As such, an entity’s written instructions and guidance for the healthcare provider (or its agent) may include multiple lines to collect a complete address. The instructions may detail the address sub-components that may be included, e.g., suite, floor, box number, bldg. number, etc.

The EFT Enrollment Rule allows for use of a single inclusive enrollment form for both EFT and ERA. Clarifying the payer and EFT and/or ERA enrollment selection is considered necessary for verifying the accuracy of the data collected from the provider and is out of scope per the CAQH CORE EFT and ERA Enrollment Data 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 offering EFT/ERA enrollment.

If an entity’s EFT enrollment process defaults to new enrollments only, there is no need to include the Reason for Submission Data Element. The data element is required only when there is more than one option for selection. The health plan or its agent must clarify in its instructions and guidance that the process is for new enrollments only.

Since the CAQH CORE Payment & Remittance EFT Enrollment Data Rule was initially developed, many organizations have identified the need to improve their fraud prevention measures. Per the rule, verifying the accuracy of the data collected from the provider is outside the scope of the rule and entities are permitted to include policies and methods to minimize fraud in their enrollment process.