Frequently Asked Questions - VII. CAQH CORE Payment & Remittance ERA Enrollment Data Rule

Yes. The CAQH CORE Payment & Remittance ERA Enrollment Data Rule vPR1.0 establishes a maximum set of data elements to be included on an ERA enrollment form, as well as a required flow and format for presentation of the data elements on the form. The CAQH CORE Payment & Remittance ERA Enrollment Data Rule does not require or prohibit entities from using an inclusive form for the purposes of ERA Enrollment, as long as the format, flow, and data set (including data element descriptions) are used as specified in rule. The CAQH CORE Payment & Remittance ERA Enrollment Data Rule specifies the timeframe for converting existing paper-based enrollment forms to comply with the rule.

NOTE: The CAQH CORE Payment & Remittance ERA Enrollment Data Rule also requires all health plans, and their agents or vendors offering ERA 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 ERA Enrollment Data Set.”

The CORE-required Maximum ERA 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 ERA 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 Payment & Remittance ERA Enrollment Data Rule vPR1.0 requirements for the CORE-required Maximum ERA Enrollment Data Set. However, the CAQH CORE Payment & Remittance ERA Enrollment Data Rule requires that the following Individual Data Elements must be collected during the ERA 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 ERA 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 CAQH CORE Payment & Remittance ERA Enrollment Data Rule vPR1.0 establishes a maximum set of data elements to be collected by the health plan from the provider for ERA enrollment, as well as a required flow and format for the data elements on a web-based or paper-based enrollment form. It does not address data elements in the X12 v5010 835 ISA and GS control segments. These data elements are outside the scope of the CAQH CORE Rule, and would need to be collected from the provider external to the ERA Enrollment process.

No. The CAQH CORE Payment & Remittance ERA Enrollment Data Rule vPR1.0, 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 ERA 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.

No. Verifying the accuracy of the data collected from the provider during the ERA 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 ERA enrollment.

Yes. A health plan (or its agent or vendor offering ERA enrollment) must collect all Individual Data Elements per the CAQH CORE Payment & Remittance ERA Enrollment Data Rule vPR1.0 requirements, including those for which the health plan has no business need.

The CORE-required Maximum ERA Enrollment Data Elements were identified after substantial industry research and analysis to compare ERA enrollment forms from across the industry. CAQH CORE Participants agreed that these data elements represented the maximum set of data elements required for successful ERA enrollment. The CORE-required Maximum ERA Enrollment Data Set includes eight Data Element Groups (DEGs) designated as required or optional for data collection. Per the CORE-required Maximum ERA Enrollment Data Elements, of the CAQH CORE Payment & Remittance ERA 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.

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.

The CAQH CORE Payment & Remittance ERA Enrollment Data Rule vPR1.0 does not define a specific format(s) that constitutes an electronic method and process for collecting the CORE-required Maximum ERA 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 ERA 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.

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 ERA Enrollment Data Rule vPR1.0 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.

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 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.

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.

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.