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

  1. Must health plans enable providers to view their enrollment status online?
  2. As a health plan, if I choose to include an optional Data Element Group (DEG) on my enrollment form, must I include all the Individual Data Elements within the DEG?
  3. As a health plan, if I collect some of the data elements in the CAQH CORE Maximum EFT Enrollment Data Set as part of another enrollment process, must I still include these data elements on my EFT enrollment form?
  4. Does the CAQH CORE Payment & Remittance EFT Enrollment Data Rule specify requirements for how health plans should verify the accuracy of the enrollment data submitted by providers?
  5. As a health plan, we have chosen the optional “Include with Enrollment Submission” Data Element to collect a voided check or bank letter for account authentication. What submission method should we use for documentation?
  6. The CAQH CORE Payment & Remittance EFT Enrollment Data Rule requires health plans offering EFT to offer an electronic method and process for collecting the information. What specific format(s) constitute an “electronic” method?
  7. The CAQH CORE Payment & Remittance EFT Enrollment Data Rule specifies several items beyond the CORE-required Enrollment Data Elements that must be included on a paper-based EFT enrollment form. Do the rules require all these items?
  8. The CAQH CORE Payment & Remittance EFT Enrollment Data Rule requires health plans to collect a signature for the individual authorized to initiate, modify, or terminate the EFT enrollment. What data collection method should be utilized?
  9. How long will my organization have to update our EFT and/or ERA enrollment system or forms after publication of substantive adjustments to the CAQH CORE EFT & ERA Enrollment Data Rules?
  10. As a health plan, if my organization chooses to include an Individual Data Element that is designated as “optional” within the CORE-required Maximum EFT Enrollment Data Set, can we make completion of this data element mandatory for enrolling providers?
  11. Can my health plan use a single form for both EFT and ERA enrollment?
  12. My health plan currently uses one inclusive form to enroll providers to receive all healthcare electronic transactions. Can we use this same form to collect CORE-required Maximum EFT Enrollment Data Elements?
  13. As a health plan, am I required to include only the Individual Data Elements within required Data Element Groups (DEGs) on my EFT Enrollment form?
  14. What Individual Data Elements must be included in the electronic enrollment method required in the CAQH CORE Payment & Remittance EFT Enrollment Data Rule?
  15. If a health plan uses a web-based enrollment method to fulfill the CORE Electronic Enrollment Safe Harbor required by the CAQH CORE Payment & Remittance EFT Enrollment Data Rule, do the data elements have to be included on a single webpage?
  16. Are there available data file examples of the CORE-required Maximum EFT Enrollment Data Set that health plans, their agents and/or vendors offering EFT Enrollment, can use to develop their enrollment form/utility?
  17. As a health plan, do we have to collect required Individual Data Elements for which we do not have a business need?
  18. As a health plan, do I conform to the CAQH CORE Payment & Remittance EFT Enrollment Data Rule requirements if I use abbreviated Data Element Names on my electronic enrollment form and provide the full Data Element Names via a “mouse hover” function?
  19. Do the CAQH CORE EFT & ERA Enrollment Data Rules specify requirements regarding whether a health plan can make provider EFT enrollment contingent upon the provider also enrolling to receive the X12 835 ERA?
  20. If a health plan offering EFT and ERA enrollment chooses to use a single form, how should the EFT and ERA Enrollment Data Element Groups in the CAQH CORE Enrollment Data Rules be presented on the form?
  21. Why does the CAQH CORE Payment & Remittance EFT Enrollment Data Rule require inclusion of both TIN and NPI as sub-elements for the “Provider Identifier” Data Element in DEG2 and “Account Number Linkage to Provider Identifier” Data Element in DEG7?
  22. How are the CAQH CORE EFT & ERA Enrollment Data Sets maintained via the CAQH CORE EFT & ERA Enrollment Data Maintenance Process?
  23. How will the CAQH CORE Enrollment Data Task Group evaluate potential substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets?
Must health plans enable providers to view their enrollment status online?

Submitted by caqh_admin on Tue, 12/22/2015 - 04:00
Must health plans enable providers to view their enrollment status online?

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.

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VI. CAQH CORE Payment & Remittance EFT Enrollment Data Rule
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As a health plan, if I choose to include an optional Data Element Group (DEG) on my enrollment form, must I include all the Individual Data Elements within the DEG?

Submitted by caqh_admin on Tue, 12/22/2015 - 04:51
As a health plan, if I choose to include an optional Data Element Group (DEG) on my enrollment form, must I include all the Individual Data Elements within the DEG?

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.
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As a health plan, if I collect some of the data elements in the CAQH CORE Maximum EFT Enrollment Data Set as part of another enrollment process, must I still include these data elements on my EFT enrollment form?

Submitted by caqh_admin on Tue, 12/22/2015 - 04:55
As a health plan, if I collect some of the data elements in the CAQH CORE Maximum EFT Enrollment Data Set as part of another enrollment process, must I still include these data elements on my EFT enrollment form?

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.

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Does the CAQH CORE Payment & Remittance EFT Enrollment Data Rule specify requirements for how health plans should verify the accuracy of the enrollment data submitted by providers?

Submitted by caqh_admin on Tue, 12/22/2015 - 05:16
Does the CAQH CORE Payment & Remittance EFT Enrollment Data Rule specify requirements for how health plans should verify the accuracy of the enrollment data submitted by 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.

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As a health plan, we have chosen the optional “Include with Enrollment Submission” Data Element to collect a voided check or bank letter for account authentication. What submission method should we use for documentation?

Submitted by caqh_admin on Tue, 12/22/2015 - 05:18
As a health plan, we have chosen the optional “Include with Enrollment Submission” Data Element to collect a voided check or bank letter for account authentication. What submission method should we use for documentation?

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.

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The CAQH CORE Payment & Remittance EFT Enrollment Data Rule requires health plans offering EFT to offer an electronic method and process for collecting the information. What specific format(s) constitute an “electronic” method?

Submitted by caqh_admin on Tue, 12/22/2015 - 05:36
The CAQH CORE Payment & Remittance EFT Enrollment Data Rule requires health plans offering EFT to offer an electronic method and process for collecting the information. What specific format(s) constitute an “electronic” method?

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.

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The CAQH CORE Payment & Remittance EFT Enrollment Data Rule specifies several items beyond the CORE-required Enrollment Data Elements that must be included on a paper-based EFT enrollment form. Do the rules require all these items?

Submitted by caqh_admin on Tue, 12/22/2015 - 22:21
The CAQH CORE Payment & Remittance EFT Enrollment Data Rule specifies several items beyond the CORE-required Enrollment Data Elements that must be included on a paper-based EFT enrollment form. Do the rules require all these items?

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.

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The CAQH CORE Payment & Remittance EFT Enrollment Data Rule requires health plans to collect a signature for the individual authorized to initiate, modify, or terminate the EFT enrollment. What data collection method should be utilized?

Submitted by caqh_admin on Tue, 12/22/2015 - 22:23
The CAQH CORE Payment & Remittance EFT Enrollment Data Rule requires health plans to collect a signature for the individual authorized to initiate, modify, or terminate the EFT enrollment. What data collection method should be utilized?

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).

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How long will my organization have to update our EFT and/or ERA enrollment system or forms after publication of substantive adjustments to the CAQH CORE EFT & ERA Enrollment Data Rules?

Submitted by caqh_admin on Tue, 12/22/2015 - 22:36
How long will my organization have to update our EFT and/or ERA enrollment system or forms after publication of substantive adjustments to the CAQH CORE EFT & ERA Enrollment Data Rules?

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.

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As a health plan, if my organization chooses to include an Individual Data Element that is designated as “optional” within the CORE-required Maximum EFT Enrollment Data Set, can we make completion of this data element mandatory for enrolling providers?

Submitted by oadekanmbi@caqh.org on Mon, 01/25/2016 - 11:48
As a health plan, if my organization chooses to include an Individual Data Element that is designated as “optional” within the CORE-required Maximum EFT Enrollment Data Set, can we make completion of this data element mandatory for enrolling providers?

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.

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Can my health plan use a single form for both EFT and ERA enrollment?

Submitted by jporras on Mon, 12/14/2020 - 09:59
Can my health plan use a single form for both EFT and ERA enrollment?

Yes. The CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 and CAQH CORE Payment & Remittance ERA Enrollment Data Rule vPR.1.0 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.

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My health plan currently uses one inclusive form to enroll providers to receive all healthcare electronic transactions. Can we use this same form to collect CORE-required Maximum EFT Enrollment Data Elements?

Submitted by jporras on Mon, 12/14/2020 - 10:04
My health plan currently uses one inclusive form to enroll providers to receive all healthcare electronic transactions. Can we use this same form to collect CORE-required Maximum EFT Enrollment Data Elements?

Yes. The CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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.”

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As a health plan, am I required to include only the Individual Data Elements within required Data Element Groups (DEGs) on my EFT Enrollment form?

Submitted by jporras on Mon, 12/14/2020 - 10:12
As a health plan, am I required to include only the Individual Data Elements within required Data Element Groups (DEGs) on my EFT Enrollment form?

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.
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What Individual Data Elements must be included in the electronic enrollment method required in the CAQH CORE Payment & Remittance EFT Enrollment Data Rule?

Submitted by jporras on Mon, 12/14/2020 - 10:18
What Individual Data Elements must be included in the electronic enrollment method required in the CAQH CORE Payment & Remittance EFT Enrollment Data Rule?

Section 4.4 of the CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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.
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If a health plan uses a web-based enrollment method to fulfill the CORE Electronic Enrollment Safe Harbor required by the CAQH CORE Payment & Remittance EFT Enrollment Data Rule, do the data elements have to be included on a single webpage?

Submitted by jporras on Mon, 12/14/2020 - 10:22
If a health plan uses a web-based enrollment method to fulfill the CORE Electronic Enrollment Safe Harbor required by the CAQH CORE Payment & Remittance EFT Enrollment Data Rule, do the data elements have to be included on a single webpage?

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

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Are there available data file examples of the CORE-required Maximum EFT Enrollment Data Set that health plans, their agents and/or vendors offering EFT Enrollment, can use to develop their enrollment form/utility?

Submitted by jporras on Mon, 12/14/2020 - 13:36
Are there available data file examples of the CORE-required Maximum EFT Enrollment Data Set that health plans, their agents and/or vendors offering EFT Enrollment, can use to develop their enrollment form/utility?

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 vPR.1.0, there are no other available data file examples of the CORE-required Maximum EFT Enrollment Data Set.

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As a health plan, do we have to collect required Individual Data Elements for which we do not have a business need?

Submitted by jporras on Mon, 12/14/2020 - 13:53
As a health plan, do we have to collect required Individual Data Elements for which we do not have a business need?

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 vPR.1.0 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 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.
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As a health plan, do I conform to the CAQH CORE Payment & Remittance EFT Enrollment Data Rule requirements if I use abbreviated Data Element Names on my electronic enrollment form and provide the full Data Element Names via a “mouse hover” function?

Submitted by jporras on Mon, 12/14/2020 - 13:58
As a health plan, do I conform to the CAQH CORE Payment & Remittance EFT Enrollment Data Rule requirements if I use abbreviated Data Element Names on my electronic enrollment form and provide the full Data Element Names via a “mouse hover” function?

No. Section 4.3.2, Master Template for Electronic Enrollment, of the CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 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.

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Do the CAQH CORE EFT & ERA Enrollment Data Rules specify requirements regarding whether a health plan can make provider EFT enrollment contingent upon the provider also enrolling to receive the X12 835 ERA?

Submitted by jporras on Mon, 12/14/2020 - 14:01
Do the CAQH CORE EFT & ERA Enrollment Data Rules specify requirements regarding whether a health plan can make provider EFT enrollment contingent upon the provider also enrolling to receive the X12 835 ERA?

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

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If a health plan offering EFT and ERA enrollment chooses to use a single form, how should the EFT and ERA Enrollment Data Element Groups in the CAQH CORE Enrollment Data Rules be presented on the form?

Submitted by jporras on Mon, 12/14/2020 - 14:52
If a health plan offering EFT and ERA enrollment chooses to use a single form, how should the EFT and ERA Enrollment Data Element Groups in the CAQH CORE Enrollment Data Rules be presented on the form?

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.

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VI. CAQH CORE Payment & Remittance EFT Enrollment Data Rule
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Why does the CAQH CORE Payment & Remittance EFT Enrollment Data Rule require inclusion of both TIN and NPI as sub-elements for the “Provider Identifier” Data Element in DEG2 and “Account Number Linkage to Provider Identifier” Data Element in DEG7?

Submitted by jporras on Mon, 12/14/2020 - 15:14
Why does the CAQH CORE Payment & Remittance EFT Enrollment Data Rule require inclusion of both TIN and NPI as sub-elements for the “Provider Identifier” Data Element in DEG2 and “Account Number Linkage to Provider Identifier” Data Element in DEG7?

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 vPR.1.0 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.

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VI. CAQH CORE Payment & Remittance EFT Enrollment Data Rule
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How are the CAQH CORE EFT & ERA Enrollment Data Sets maintained via the CAQH CORE EFT & ERA Enrollment Data Maintenance Process?

Submitted by jporras on Mon, 12/14/2020 - 15:35
How are the CAQH CORE EFT & ERA Enrollment Data Sets maintained via the CAQH CORE EFT & ERA Enrollment Data Maintenance Process?

As specified in Section 3.4, CORE Process for Maintaining CORE-required Maximum EFT Enrollment Data Set, of the CAQH CORE Payment & Remittance EFT Enrollment Data Rule vPR.1.0 and CAQH CORE Payment & Remittance ERA Enrollment Data Rule vPR.1.0, 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 Payment & Remittance EFT and ERA Enrollment Data 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 CAQH 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 workflows 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.

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VI. CAQH CORE Payment & Remittance EFT Enrollment Data Rule
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How will the CAQH CORE Enrollment Data Task Group evaluate potential substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets?

Submitted by jporras on Mon, 12/14/2020 - 15:40
How will the CAQH CORE Enrollment Data Task Group evaluate potential substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets?

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 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.

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VI. CAQH CORE Payment & Remittance EFT Enrollment Data Rule
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